85-901 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 4.r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED' ' + (Complete in Triplicate) 1� rH L_ .�. 1 .."�.. .: ,.: •.. .- .. Y Y. :.: �:''J�..' ',y'e �yy - ! --r 1 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 withSan Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules.and Regulations of the San Joaquin Local Healih'District. ..'r Job Address .[ I t7�[.�- 1 ty� Ii Yf Ci ' Lot Size PM Owner's Name Address-1910440e/ Phone �r AO�Cvntrac#or Addres,�wlry !� License No: Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANO SEWER LINES DISPOSAL FLD. PROP. LINE Y" FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. De th ❑ Eastern Surface Seal Installed by Repair Work Done El of Pump H.P. 5L: State Work one Well Destruction 11 Well Diameter f Sealing Material (top 50') Depth Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ))j available within 200 feet.) ; Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: --+ Water table depth SEPTIC TANK ❑ Type/Mfg - !Capacity k No. Compartments ' PKG. TREATMENT PLT. ❑ �' f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size S 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contra%c grms 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 rsohs subject to workman's compensa- tion laws of California." 5 -7- The applicant , s�t call r all required inspections. Complete drawing o verse side. Signed XJ Title: � � Da' a: FOR DEPARTMENT USE ONLY a g Application Accepted by Date 7-2 'Afea d et r� Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621.1 ❑ 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 A a ! FEE AMOUNT DUEt, AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 1324(REV. /a 5) EH 1426 1 I O•Z-- Y 4--' — d r