85-1152 - Laserfiche WebLink

Home Browse Search

l ' APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES1 YEAR FROM DATE ISSUED' tt (Complete in Triplicate) 5-r i 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. 1862for wellkpump and the Riles a6d'Regulations of the San Joaquin i Local Health District y' ti/i+�r- ' ` Lot Size t i.a€�7 PM } I. Job Address , City n� - 2 �1 ddress — Phone �d 6 -0 Owner's Name- • • I"1 ! V License No Phone Contractor Address + TYPE OF WELL/PUMP: NEW WELL ❑ " WELL REPLACEMENT ❑ DESTRUCTION El " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Vv DISTANCE ° DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.-� _.._.,....,--_.INTENDED-USE--17.�--•-�-TYPE-OF,:WEL-L— PROBLEM AREA- CONSTRUCTION-SPECIFIGATIONS 4 y ,_� :s I ❑ Industrial E3 Open Bottom C1 Manteca Dia. of Well Excavation -" Dia. of Well Casing f Type of Casin -•�"� %—Specifications ❑ Domestic/Private ❑ Gravel Pack ❑xTracy g ❑..Public. i?`i�' L2 Other t _ ❑'D`elta 1Z �� x°Depth of,.Grout 5ealr ' Type of Grout { w. -� ,- "� ❑ Irrigation � !�f,_A5pprox#Depth ❑ Eastern Surface Seal Installed by - • H.P. _ State Work Done Repair Work Done LlType of Pumps _ _ Well Destruction ❑f Well.Diametef Sealing Material {top 501 epth}' g Filler Material IBelow 50') d TYPE OF,SEPTIC WORK: NEW,'INSTA'LLATIONREPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is }A available within 200 feet.) z- (11 I Installation will serve:�/Residence'i;; mmerpial:,y k=" Othryer - t`" a '1�iumbefof bedrooms umber of living units: Character of soil to a deptho 3:ee "'' it � Water ble`depth I ` Capacity If�DG No. Compartme is SEPTIG TANK "TypeLMfg -- r, '---Method of Disposal • PICS TREATMENT PL'T`❑ --^-' .v �/ �/.' property Line Distance to nearest` Well-��— Foundation n t ' � =ti.s`❑I tTotal IerSgth/size'• LEACHING LINE No. & Lengh of lines Well Foundation rop FILTER BED L1 Distance to nearest: er(y Line ' } - SEEPAGE PITS ❑j Depth Size F SUMPS Cl Distanceto-nearest: Well Foundation Property Line DISPOSAL PONDS ❑ at the work will be done in accordancwith San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and th rules and regulations of the San Joaquiri Local Health District.-----� Home owner or licensed agent's signature certifies the following: "I certify thaf`in the performance of the work fo,,which this permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of California.'Contractors hiring or sub-contracting signature , ersons sub' to workman's compensa- certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall emplo pYa fec# tion laws of California." ! { S s , The applicant ust call all r w d Siins ctions. Complete drawing on revers side Z i f Tit e: � " �' _, Date: ` 7 gned f rt FO DEPARTMENT USE ONLY tt I Application Accept d by Date "}z Area Pit a5-Grout Inspection by Date�� nal Inspection by Date Additional Comments:--_v-- . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 �r -r � - t""� ^•5-Y,..., i E 4 FEE _CK. w' .r RECEIVED BY DATE- PERMIT`NO. INFO AMOUNT DUE AMOUNT REMITTED CASH- -_ + EH 13-24 TREY.1/a 51 EH 1428