85-1217 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TION 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. `�(j[�! �Y pG�✓`� '�1 � Job Address -� City f� Lot Size PM /U{h� 'v� �(~ �� Q �- W T/ / � Phone s Owner's Name Address 41 grO'7 ° Contractor dr s rJ 1 Q License No. r ��' � Phone '+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDEST UCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �u + r FOUNDATION"" AGRICULTURE WELL OTHER WELLS PITS/SUMPS INTENDED USE TYPE OF WELL. }i',PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia.'of.Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth _E] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter, Sealing;Material (top 501 Depth- j a Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ iDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ("ti Installation will serve: Residence if!! Commercial— Other SGL pC?� `�i�i.✓�- ~J Number of living units: �� Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK le Type/Mfg V&n�_S d+ ;1o� Capacity � ;:No. Compartments � PKG. TREATMENT PLT:„Pl”' t '' '�yl �.$fao—:J` y0 4`J/ A Method of Disposal x t 4 t Distance to nearest: s Well Foundation Property Line i) LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ; ❑ Distance to nearest: Well Foundation Property Line f � SEEPAGE PITS ❑ Depth Size Number SUMPS ;ElDistance to nearest: Well Foundation Property Line F "_ DISPOSAL PONDS :❑ 6� 3 � c - I hereby certify that I have 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 shat! not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 4 1 1 The applicant ust call r all r uir d inspe tions. Complete drawing on rever side. + Signed Title: �v%►:•. Date: ! l5 c # r 1 FOR DEPARTMENT USE ONLY Application Accepted by Date /Q Area Pit or Grout Inspection by D�te Final Inspection by / Date �-' k 1 Additional Comments:j�_-J`<32-s Y ✓ 3 �� `v '` `�'�` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385, eld,K,r Applicant- Return allopies to: Environmental HealthP rrrnit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Cu�a >cu �i, 6cLac_ 30� Uiiif FEE ! AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO {�.[ .''EH 13-24(REV,1/85) in c, I 11\0 �` S Zt • 'EH 1426 l4 / -