85-720 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN 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 L H, City 1r7C� Lot Size PM Owner's Name M/V a, 1 0 Address 0Z Phone 3 -7°� I Contractor L �'gtLt �-�!� Addresses �1-��a ._t_ License No. C3_ .� ?MlPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE :. TYPE OF WELL 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 ❑ 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 Filler Material (Below 50') TYPE OF SEPTIC WO'RK: NEW INSTALLATION REPAIR/ADDITION 13DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_,, �Other , Number of living units: t Numtier of bedrooms Character of soil to a depth of 3 feet: "', Water table depth SEPTIC TANK Type/Mfg � ra '-tc- CapacityY.t,G_0eNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest:. Well Foundation Property Line 14 S f r LEACHING LINE © No. & Length of lines Total length/size el c FILTER BED ❑ Distance to nearest: Well w Foundation -1?,> Property Line SEEPAGE PITS ❑ Depth Size Number`�— r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that-th�worRwvill'bed6rie"in accordance with San Joaquin county ordinances, state laws, and A 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 tivork 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: '9 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 f all re Aired inspections._Complete drawing 6n reVerse aide.-" Signed Title:,- �� _ Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by " _ Date �� Area Q [ Pit or Grout Inspection by Date Final Inspection by 5 ��" r Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83&40% Applicant- Return all copies fo:'Envirorimental Health Permit/Services- 1601 E. Hazelton AveP.O. Box 2009, Stk., CA 95201 FEE INFO O�jU'NT/jDyU�E AMOUNT REMITTED_ CASH RECEIVED BY 7 DATE PERMIT NO. + EH 14-261REV.t/65l