85-1382 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. •* Job Address 274y� r ° City !`t''2 Lot Size's gtKE PM Owner's Name SRUCIE R06C0+-S0t4- Address 7902 1J. L>NNe 6n2W1LY)=Phone Contractor BaRRism Address ,4Z0 Sr' /J License No._2,4� 393 Phone & - 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION ❑ i. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE PO FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WeII Excavation Dia. of Well Casing N Domestic/Private ❑-Gravel Pack, ❑ Tracy TV "Yof Casing 'f = t� Specifications ❑ Public ❑ Other (9-Delta D]Dth of Grout Seal"--" Type of Grout ❑ Irrigation L-,pprox�Depth ❑%Easter—"--1 '-u/u ace Seal.InstalleI `� Repair Work Done ❑ Type of.Pump H;p, State Work Done Well Destruction ❑ Well Diameter Sealin `Material (top 50') Depth I i 1Fillef Material (Bel3w.50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ =REPAIR/ADDITION ■ DESTRUCTION ❑ iNo septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence.-�L Commercial Others •� i Number of living units: �__ ,Number of bedrooms _ Character of soil to a depth of 3 feet: SI ! _ � �Water table depth 2.00 SEPTIC TANK Type/Mfg Capacity`1.2!2 No. Compartments PKG. TREATMENT PLT. ❑ '""" ` " `� Method of Disposal Distance to nearest: Well_I 00' Foundatiori •,'Z� Property Line I Do L E 19 -No. & Length of lines Total length/size—Q FILTER BED ■ Distance to nearest:. Well 100 Foundation_?,r', Property Line—[00� r �f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E3 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTME T USE ONLY Application Accepted by v Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY INFO CASH DATE PERlVl1T"NO, +EH 13-24(REV.5/E51 EH 1428 �! r _ r