85-525 - 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) 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 R41es and Regulations of the San Joaquin i Local Health District.. I I AC Job Address 9,2,q City -4AT_ ei2;T Lot Size / PM 1 Owner's Name AF-P G�xJ�T.1� _ Address Phone Contractor G Address S7O0 /'�T 4' License-Nn_,'-,�-fT%Q Phone y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 6 Repair Work Done ❑ Type of Pump H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth.of 3 feet: SA-ey'oIV Lem -,*t Water table depth SEPTIC TANK ID/tType/MfgCapacity__l� No. Compartments UI PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /1/ —47 Foundation Property Line LEACHING LINE ❑ No. & Length of lines � �(�/r� Total length/size r FILTER BED Distance to nearest: y Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature f 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 California." The applicant must call for alZu"red inspections. Complete drawing on reverse side. Signed X /�ae/ Title: Date: FOR DEPARTMENT USE ONLY 2 Application Accepted by _ r A— - _-Date-' - Pit or Grout Inspection by Data / ' Final Inspection by Dates—il"5 Additional Comments: ff 13Stk 466-6781 , ❑'Lodi" 369-3621 El Man teca 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 952011 h . FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT''NO. INFO CASH EH13-241REV,1/851 EH 1426