85-350 - 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 (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 well/pump and the Ryles and Regulations of the San Joaquin Local Health District. }' Job Address City Lot Size PM e r/ � � Owner's Name � � Address Phone c� 7 �7p Y 1 Contract l a Addressha a �✓ N / License No.J�tr3 c Phon ��r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE —.-.-TYPE.OF WELL _PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public', ,_- . .- ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I❑ Irrigation --Approx. Depth\ ❑ Eastern k Surface Seal Installed by O 'Repair Work Done ❑ Type of Pump H.P. Statee Woik Done Well Destruction ❑ Well Diameter Sealing Material {fop 501 x ' Depth Filler Material (Below 50') C TYPE OF.SEPTIC WORK: NEW INSTALLATION PK REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " --available within 200 feet.) L I / -_tom' ,` Installation will serve: Residence_ Commercial— Other 3., .4 "` _� "fS , i Number of living-units:-_./__._.,,_Number edroorns _ - 4 Character of soil to a depth of 3 feet: �'t ' '-_ _ "" �' Water table depth--- ra SEPTIC TANK Q- Type/Mfg �C2 Z1 f Capacity r90 6 i-s No. Compartment;11— PKG..TREATMENT PLT. ❑'` / E� Method of Dpposal---. - Distance to nearest: {^Well Foundation T� Property Line S .r LEACHING LINE p z<No. & Lerigth of lines f p '� Total length/size go A a ` FILTER BED ElDistance to nearest: Well_.— Foundation _fid property Line SEEPAGE PITS T �R' Depth r s Size %tt. Number SUMPS -i .-- ❑- -Distance to nearest: (Nell 0 1 Foundation __ Property Line S DISPOSAL PONDS ❑ I hereby certify that-I have prepared #his application and that the work ail]be aone'in accordance with San Joaquin county ordinances, state laws, andZ. ' irules and regulations of the San Joaquin Local Health District. l (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 1 certrtifies 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 California." i The applicant rTist call for a req ired inspections. Complete drawing on reverse side. I �� Date: 7 �� ' Title: Sign_ed i FOR DEPARTMENT USE ONLY Application Accepted by ` T Date Area i it r Grout Inspection by Date aminal Inspection by �" Date `b Z Additional-Comments:-= ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. r INFO CASH + EH13-241REV.t/B5) JI EH 14-26 n