85-1470 - Laserfiche WebLink

Home Browse Search

k APPLICATION.FOR PERMIT {• SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 . PERMIT EXPIRES 1.YEAR FROM DATE ISSUED •{Com lete 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. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District Job AddressS City X'011 Lot Size PM Owner's Name Address Phone is Contractor f IS ddressI $v �?�- �' g If f �r . , icenseINo_ J/ Phone_ TYPE OF WELL/PUMP: NEW WELL p WELL REPLACEMENT ❑ l DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ I SEWER LINES DISPOSAL FLD. PROP. LINE ��. FOUNDATION AGRICULTURE WELL OTHER WELL ------------- PITS/SUMPS INTENDED USETYPE OF WEU�,JPPROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial r -.❑..Opera_Bottom,, _E1. Dia. of Well Excavation ) Q Domestic/Private ❑ Gravel Pack r L f. Dia. of Well Casing ❑ Tracy r. Type of Casing' ❑ Public Specifications t —t :. r ❑ Other 1 ❑ Delta;.'(r .Depth of Grout Seal r r. Type of Grout O irrigation. Y ---Approx. Depth ❑ Easte n " _ �,;-> �- lf- ).Surface�Seal-Instailed-by Repair Work Done Cf 'Type of Pump ._ FI.P,. . " ,. r S tate Work Done Well Destruction C7 Well Diameter ' Sealing Materials{=op 501 ,,Depth, Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence availbble-`withirl 200 feet.) s Commercial_ Other Number of living units: Number of bedrooms—2. ! Character of soil to a depth of 3 feet: I SEPTIC TANK Water table depth ❑ Y ;y Type/Mfg Capacity No.-Compartments 1 _ PKG. TREATMENT PLT. ❑ + .. �. r # -. w `�' r Well Method of Disposal Distance to nearest: _/4� Foundation Property Line �� r LEACHING LINE ``t sF-� ❑ No. & Length of lines _ _�Tota! length/size FILTER BED ❑ Distance to'nearest: Well 1 M��{ x ��, r �.-t�s,�_' Foundation�__ Property Line SEEPAGE PITS ❑ Depth 1' Size SUMPS - Number Q Distance to nearest: Well�'�*• Foundation s• 3 . I DISPOSAL PONDS ❑ Property Line s I hereby certify that I have prepared this application and that the work will be done in ac ordance with San Joaquin county ordinances, state laws, and } I rules and regulations of the San Joaquin Local Health District. "`""^-"`�•^�..a„sa,� _ 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 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." =h Thea an ust callforall require " spections. Complete drawing on reverse side. Signed l s Title:- R Date: FOR DEPARTMENT USE ONLY E Application Accepted by Date i Area Pi Grout Inspection by to Fin I In ction by bate lattq' 1 j 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. .-:..�.--•----•'---.._ _ ,__. - ..-.... . ,�.,,,_„. C INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY —� DATE PERMIT •N0. + EH' 24(REV.>/H 51 We�� ,1 EH 1428 i Ll +.