85-593 - Laserfiche WebLink

Home Browse Search

APPLICATI-ON,FOR_PERMIT SAN JOAO,UIN:LOCAL:-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209.) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ., , . ,_ �*..: : r'a+ _,:-. � Nt•,4(Complete in Triplicate)y' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicationismade incompliance with San Joaquin County.Ordinance No.549 for-sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. d ': € :. 't 'R�r ,> w; ..-. I « Job Address City _ Lot Size PMT Owner's Name '] Address Phone Contractor's Name License No. 6Z—` Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK 4., SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ln 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 00 LIIrrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done Q Type of Pump H,P. 9V4 State Work Done Well Destruction ❑ Well Diameter Sealing-'Mgrial (top 50') Depth r Filler Material (Below 501 , TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bed-rooms S Character of soil to a depth of 3 feet: - -Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _❑ 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, 1 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:"l certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applica d al .for all requires''spections. Complete drawing on reverse side. Signed Title: Date: fi F R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by i Date Final inspection by Additional Comments: + Q Stk 466-6781 ❑ Lodi 3693621 ># ❑ Manteca 823-7104" r Q Tracy 835-638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED B_Y DATE PERMIT"NO. '+ EH 13.24 IREV.10/83) EH 1428.