85-995 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES '(`YEAR FROM DATE 'ISSUED k (Complete in Triplicate)—,."'.. .. } . � hcation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app 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 itLocal Health District. , �j� 7O �{N Lot Size Job Address '- City PM..r ' I` Sl��YI� g z - Owner's Name Address — Phone — 5Y5 ��f Phone Address Zto License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION LJ PUMP INSTALLATION *7/QE,'yG9,72iWTEM REPAIR ElOTHER 12I 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- INTENDED pia. of Well Casing El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation ---Approx. Depth Eastern Surface S El Irrigation Installed by Repair Work Done ❑ Type of Pump— H.P. �� State Work Done Sealing Well Destruction ❑ Well Diameter 9 Material {top 50') Depth Filler Material IBelow 501 05 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is l 5t—lj� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other j. Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT: 71Method of Disposal 9/ a Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No.'& Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. t 1, . . .. 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: 111 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." a- The applicant st c fo li re�e �specvons. on reverse. Signed,N— Title: p/!s Date: l ! + FOR DEPARTM T USE ONLY Application Accepted by Date - Area o 'Pif di Grout Inspection �F iiy—=t==: Datee "Final Irispectibn liy' Date i' Additional Comments: l t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . -,E1 j acy,'�>335-6365 f Applicant- Return all copies to: Environmental Health Permit/Services 1601"E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �r 4 FEE AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED 8Y- DATE PERMIT:NO. 1 - -INFO Q r +EH 13-24(REV.1/851 1S J - �`2' �3 —q `S EH 1428