85-1185 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , w! (Complete in Triplicate) u 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 Local Health District. F. q `' Job Address 63 11 City Loi Size_/0 /1 PM Owner's Name Address 9 19 /Y U t1 4 A/C Phone . tti� S Contractor's Name eG — License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ` 3.: DESTRUC`fION ❑ `i."' PUMP'INSTALLATION�❑ -' SYSTEM REPAIR El OTHER ❑ a _.. DISTANCE TO NEAREST:..SEPTIC TANK SEWER LINES •DiSPOSALIFLD:'" PROP:.LINE FOUNDATION AGRICULTURE WELL OTHER WELL R PITS/SUMPS INTENDED USE TYPE OF WELL' PI=MROBLAREA' CONSTRUCTION SPECIFICATIONS ❑ fndustrialt. ❑ Open Bottom ❑ Manteca E ' ,.Z.,Dia.-6f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type'o Casing Specifications = ' ❑ Public ❑ Other ❑ Delta r Depth of Grout Seal Type of Grout ❑ Irrigation; ---�Approx. Depth ❑ Eastern " Surface Seal.Installed by Repair Work Done ❑ Type of Pump E e',H:P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 50') Depth I f ;Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is 1 Bt available within 200 feet.) Installation will serve: Residence Commercial Other �Lt� g eA C (AV a ,' he//N Number df'living units: Number of bedrooms T 4--el xdj-f•!SeXT Characterrof soil to a depth of 3 feet: D Water table depth SEPTIC TANK ❑ Type/Mfg ;�,A�.r 7�/,�r�' Ca ac ®9 1 No. Compartments PKG EATMENT PLT. ❑ z ' 0', Method of Disposal , ii„ 4 4 Dis#anc`e`to nearest:"'""Well:�=Foundation Property Line LEACHING LINE _. : No. & Length of tines. F Total length/size �? FILTER BED ;" t❑ Distance to nearest: Well ��da Foundation Proper`ty_ Line SEEPAGE PITS ( Depth _ � ., -Size .Number � e , SUMPS ❑ Distance to nearest: Well Foundation_199 r "Property Line '—%S 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,lstate laws, and'.,. � r rules and regulations of the San Joaquin Local Health District. - . - - - , _ �j. 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 Cal'rfornia." The applicant must call for all r9pulred ins ti ns. Complete drawing on reverse sid c 4 Signed X Title: Date: `v t � - y FOR DEPARTMENT USE ONLY # t� Application Accepted by 0 9 Date �Ql Area o;7, 5 Pit or Grout inspection by Dateli Final Inspection by Date�� Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. + EH 13.24(REV.101831 EH (:!5 1428