85-992 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �� + SAN JOAQUIN LOCAL'14EALTH DISTRICT 1601 E. HAZELTON AVE.,'_STOCKTON, CA Telephone {209} 466-6781 I ` PERMIT EXPIRES 1,YEAR FROM DATE ISSUED ' t (Complete in'Triplicate) r ' 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. �w:�`� �/ Job Address 6th P�5' �7J ��. e t , City Lot Size W T'rtts EO PM Owner's Name — Address - Phone r 3 9 /'. �a� Contractor Address License No. Phony - xe 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 1 FOUNDATION! AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k #-❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ot-Welltxcavation `r 1 Dia. of Well Casing +T_.Z:DomesticlPrivate--E],Gravel-PacIC ❑-Tra'b"y'"`""""""�""°'Typeof Casing 5pecifcations O Public ❑ Other ❑ Delta De th of Grout Seal 1 r-, ::, � - � P . Type,of Grout ! ❑ irrigation �pprox. Depth\ O.�Eastern R A j_ } Surface Seal,,lnstailedby Repair Work Done ❑ Type of Pump'I H.P. State Work Done a t QII,Destiuction ❑ Well Diameter.k� Sealing Material [top 501 Depth I Filter Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 13 (No septic system permitted if public sewer is� available within 200 feet.) r F Installation will serve: Residence_ Commercial.�_( Other 1� i! `Number of living units: Numberlof bedrooms � :I d Character of soil to a depth of 3 feet: Water table depth 35 SEPTIC TANK ElType/Mtg Capacity / $2 __ No. Compartments i PKG. TREATMENT PLT. ❑ F Method of Disposal ` s Distance to nearest: Well Fou.ndation.- Property Line L'ACHING LINE Length 'of& Lengt;of lines Total length/siie FIL='f ER BED Distance to nearest: Well Foundation�( _ proLine- * €% I party _ '� SEEPAGE PITS © Depth . "Size Number r*, Ni-_SUM PS Distance to nieiarest: Well Foundation—_ /D Property Line 5r ;£✓ DISPOSAL PONDS ❑. 1 ¢ x, ! 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 f:� rules 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 .4 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature s certifies the following:"I certify,tflat'in the performance of the work for which this permit is issued, I shall employ 1 tion laws of Cal' ia.,, r ! Persons subject to workman's compensa- tion The appiican must r I equ'ed ns ctions. Complete drawing on re side. • Signed p_ Title: Date: � >( r FOR DE ARTMENT:USE O [Y Application Accepted by r" ! _207— Area r Date 'f Pit or Grout.ln pection;hy \ Date ' Final fnspectlnn by Date SL s I Additional.Comments: � � r_ _...w....,....."...�,..�,,..,,...,_ �.. Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 r , FEE AMOUNT DUE AMOUNT REMITTED INFO CASH ERECEIVED DATE PERMIT'IVO.+ EH 13-24 PREY.i/8 4, �`EH 1426 �. _r )`/ :firL • 'L" �. `/�a--O