85-185 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone 12091 466-67.81 �# E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �—u :* „(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 wail/pump and the Rules and Regulations of the San Joaquin Local Health District. i;, q� �,r, r City�- f Lot Size PM I Job Address + - Owner's Name Address U Phone Contractor's Nam License No Phon oc C3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T0_NEAREST:-SEPTIC TANK _ SEWER LINESI. f DISPOSAL_FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I] Industrial F] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � P ❑ Public ❑ Other ❑ Delta Depth of Grout SealType of Grout " ❑ Irrigation --Approx. Depth ❑ Eastern Surface.Seal installed by S t Repair Work Done ❑ Type of Pump H.P. State Work Done Sealing Material (top 50'1 r ' Well Destruction ❑ Well Diameter 9 Depth Filler Material (Below 501 ;' f 0 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic"system permitted if public sewer is !I zCommercial available within 200 feet.lInstallation will serve: .Residence Other ' ! : Number of living units: !;r/ Number f br ms Character of soil to a deptt of 3.feet: _' Water table depth "SEPTIC TANK_ _ a0 Type/Mfg — -�Capacity" No_Compartments w PKG. TREATMENT PLT. IJf Method of Disposal Distance to nearest: Well Foundation Property Line 6/6 LEACHING LINE 0-,No. & Length-of lines w dotal length/size FILTER BED ❑'_ Distance to nearest: Welll)C� Foundation /90 Property Line=� SEEPAGE PITS `Depth Size 13 Number I i SUMPS ❑ Distance to nearest: Well `Foundation — Property Line — " DISPOSAL PONDS ❑ i� �? � '�- .__.r.��v.-._-_.,.N..-_ , 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 i rules and regulations of the San Joaquin Local Health District. issued, I shall not' Home owner or licensed agent's signature'certifies the following: "I certify that in the performance of the work for which this permit is employ any person in such manner as to-become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature - l k certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California. The applican ust call f all quired inspections. Complete drawiiib on reverse side. J- Signed Title: Date: .� l�' FOR D PARTMENT USE ONLY 4 IS Date Area I plication Accepted by Pft o Grout Inspection by " Date3'Sf s� Final Inspection by �.c� 'f - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/ Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK " 11 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13.24(REV.101831 d �S &5 I EH W28 s