85-1164 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r SAN .lOAOUIN`LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Tefephone(209) 466''6781 PERMIT EXPIRES:1 YEAR FROM DATE 19SUED" X : �- ,, ,.... ,� ,�..a.,�. , .�rtL�,_ ,� ri.a�,:�� ,iry rx.�p't�tJ fi,.. } is"h.1"a`i4 ♦. � 1`.' �` ti. 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 Rules�and+Regulations of the San Joaquin "W 1U f"1.- i,.,.� v' 'rNrl.d.' + Local Health District. s�tv ` t4` f. i ."�}`jr t »� Job Address - s T7��J/.+� 'O tet' "`Ciry` S%/� m�' tot Stze �JIC lS`�.` pM t Y .a,.-^♦ 0 f'i.'01""N '4Q y1,53g01q Qrltriloibis no 3c . _ ►5 t. �. _- X37-...'.L�;- "LAIV7-. Y r . :Phone—=—. Owner's Name �� Address' t Contractor Q -Address �d - 'License No. 2S __4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ --'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR .E] 1: 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 ElOpen Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type ofCasingSpecifications 71 Public F-1 Other ❑ Delta Depth of GroutYSea! Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by M Repair Work Done ❑ Type of Pump $ H.P. State Work.Done Well Destruction Ll Well Diameter i Sealing Material stop 50'1 I Depth $ Filler Material (Bell E;0') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION -DESTRUCTION ❑ (No septic system permitted if public sewer is y r y available within 200 feet.) Installation will serve: Residence_P_ Commercial•_ Other_ >� Number of living units: Number of bedrooms' '" I Character of soil to a depth of 3 feet: r L `i — '. Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity, No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: ,?Well Foundation f Property Line LEACHING LINE ❑ No. & Length of lines— Total length/size `! F FILTER BED EI Distance to nearest: e I Foundation Property Line. 1 SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well_, Foundation Property Line _ s k DISPOSAL PONDS ❑ ' I hefeby 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. - I Home owner or licensed agent's signature certifies•the•following. "(-certify that'!n Ute performance of the work for which this permit is issued;I shall not F employ any person in such mariner 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." ` !.The applicant must call Jor all r quired inspect io y. Complete drawing,on reverse side. j. Signed Title: Date: l k # a. FOR DEPARTMENT USE ONLY r Application Accepted by Date— I Area } Date 1 r n _ Final Inspection by Date Pit or Grout Inspection by i 3 t Additional Comments: ElStk 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 �, OA$H` - RECEIVED BY DATE. PERMIT`ND. INFO +EH 1324(REV.t/a 51 - v $s. b .Y EH 14-25 - i