85-489 - Laserfiche WebLink

Home Browse Search

h y 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 1. Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Rules and Regulations of the San Joaquin I Local Health District. Job Address 'A-A+ T?0 �m)LOS4 City `-''®arw Lot Size_ 3 jq< - PM Owner's Name Q kla Address /f Phone 3� ST�4N1 5 _ r�/� S�tmck7b�r/ , Contractor's ame +' � �a l�, License No�1'/��sls Phone � F TYPE OF WELL/PUMP: 9ENAI WELL' ❑ WELL REPLACEMENT ❑d.` e. + DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP05AL FLD. _PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W ( ❑ 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 ❑ Irrigation _ _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 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.i Installation will serve: R ence_ Commercial— Other t Number of living units: Number of ttedrooms_ D [> / lterntsoil to a depth of 3 feet: `� Water table depth SE ❑ Type/Mfg Capacity— �e..�1 o. Compartments k PKG.TREATMENT PLT: ❑ 6,414 r) � X -6 f r�'rr16PAI thod of Disposal Distance to nearest: Well ? Foundation ' Property Line LEACHING LINE No. & Length of lines T I length/size Q FILTER BED Distance to nearest: Well Foundation Property Line • f SEEPAGE PITS 'Tr—Depth Size 3 Number SUMPS ❑ Distance to nearest: Well Foundation t Property Line DISPOSAL PONDS ❑ k I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin Local Health District. w , 4 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 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 o California." The app must c for I r fired ins ctions. Complete drawing reverse e: k 0. Signed Title. Date: FOR DEPART NT USE ONLY i Application Accepted by Date Areay Pit or Grout Inspection by Date Final Inspection Date.5 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 ,• I • FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT`NO. INFO +EH13-24(REV.10/831 1 M All EH 1426