85-315 - Laserfiche WebLink

Home Browse Search

APPLICATION FCR PERMIT SAN JOAQLIN LOCAL HEALTH DISTRICT 1fiG1 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6181 PERMIT EXPIRES 1 YEAR FROM HATE ISSUED 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 Rg�I ti ns of the San Joaquin Local Health District. Job Address +7 CA Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone •� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑f Industrial U Open Bottom [—] Manteca Dia, of Well Excavation L_I Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public CI Other Delta �jIrrigation Approx. Eastern Type of Casing ❑ Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done F] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 5O') Depth Filler Material (Below 50') .. TYPE OF SEPTIC WORK; NEW INSTALLATION, REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence,, Commercial Other Number of living units: f Number of bAdrooms Lot size '16,U, 4C&Zd, Character of sail to a depth of 3 feet: Water table depth 6 SEPTIC TANK ] Type/Mfg Capacity f No. Compartments PZ PKG. TREATMENT PLT. Type/Mfg Capacity Method of"Disposal SEWAGE SYSTEM �( Distance to nearest: Well Foundation Property Line DESTRUCTION JAN LEACHING LINE ' No. & Length of lines PDX 'Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size '� r lV Number 0� SUMPS Distance to nearest: Well Foundation S Property Line 3 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance witis 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 workmanis 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 compensation laws of California." The applicant mu t call r all require ections. Complete drawing on reverse side. +y Signed X Title: j/ ��/ Date: OR DEPA TMLNT USE ONLY n,9Q�k Applicatio Accepted by Area Stk 466-6781 `]�� A ional Comments: Lodi 369-3621 '' Grout Inspection byDate ��=S! Manteca 823-7104 /d};p o pal Inspection by . AA;C Date — 5� Cj Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �7DATE pPERMIT N0. INFO EH 13-24 REV, 10/82 P� CAL- 1 10/82 500 14-26