85-403 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED >' (Complete in Triplicate);' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. G Job Address ! � �l"l��C� .�� ?1 t",�/Lj/'r .. . City Lot Size PM Owner's Name �_.. Address Phone r Contractor /eo?v Address cow"o-C��Z'2—License No. TYPE OF WELL/PUMP: NEWIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ !''OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. t PROP. LINE t FOUNDATION # AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF/WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. El Tracy Type of Casin 9 Specifications :.: ❑ Public ❑ Other T ❑ Delta Depth„of Grout Seal {- Type of Grout `' v�.Irrigation --Approx. Depth El Eastern Surface Seal Installed by—.. Repair Work Done ❑ Type of Pumps i H.P. State Work Done ni 1 Well Destruction L7 Well Diameter —, Sealing Material {top 50;} k, Depth Filler Material (Below 501 )1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITIONdL---DESTRUCTION ❑ (No septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence_ Commercial Other Number qf-iving units: ` Number of bedrooms Character of soil to a depth of 3 feet: ' ` -J Water tafile depth SEPTIC TANK ❑ Type/Mfg Y''ti r*' j Capacity No. Compartments a PKG. TREATMENT PLT. ❑ t. ......... �f I Method ofDisposal ! r ` ✓ DiseFoundation Property Line " tance to nearest: Well,s } LEACHING LINE 101—IN O'& Length of lines I Total length/size ' +, FILTER BED = ❑ . Distance to nearest: Well Foundation �� Property Line r �! SEEPAGE PITS - ❑ Depth —_, Sl Number€ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that LhWe prepared this application and that the work will be done in accordance with'San Joaquin county ordinances, state laws, and rules and regulations of,the:San Joaquin Local Health District. Home owner or.'licensed,agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pefson 6 such:manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature certifies the following: "I certify that in the pe`rformance'of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 11 .. ..A % The applicant must call I require inspe Completed awing on reverse side. { .r SignedTit r le: Dater FOR DEPARTMENT USE ONLY' ;, �. Application Accepted by - �� "� `-'-"""'��pate � � f•^°' �� £Area Pit or Grout Inspection by / 5- 'd .r � _ Date ` Final inspection by �-�y�5-r��twpate�.�,C�,, Additional Comments: ❑ Stk 466-6781 ❑ Lodi369 3fi21 anteca 823-7104 Ll Tracy 8355-6385 Applicant- Return all copies to: Environmental ea Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE' AMOUNT DUE AMOUNT REMITTED CK 'RECEIVED BY fNFO CASH DATE PERRMI-r NO. + EH 1324{REV.1/857 EH 7426 r•'It'_ Gi{ S _''1i"('Z"�S i