85-341 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA -�Teiephone (209) 466-6781 All ;PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED ' _r _ y,, (Complete in Triplicated -;G Application is hereby made to the Sart Joaquin Local Health District for a permit to construct andlor install the work herein described.This application is made a compliance mt San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ��* Lot Size PM City )( ,._. Job Address 6 ,y,� Phone- Owner's Name if�.�..-� O d� zTuhu 4- Address Address License-No; .-- Phone Contactor WELL REPLACEMENT ❑ DESTRUCTION Q TYPE OF WELL/PUMP: NEW WELL .- �\ THER ❑ SYSTEM REPAIR 17 _p. . _ µ PUMP INSTALLATION ,-.-_,-.�, 4...- µ PROP. LINET SEWER LINES �..� DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS. FOUNDATION AGRICULTURE WELL r , s -� INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATION Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I D Industrial Specifications . ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Domesticl-Private 4 Type of Grout J ❑ Other f ❑ Delta Depth of Grout Seal ❑ Public t._ Surface Seal Installed by El Irrigation --Approx. Depth ❑ Eastern ! H P State Work Done f. Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 � g, 1 Well Destruction ❑ Well Diameter Filler Material (Below 50'1 Depth. - availabte within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION�REPAiR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence Commercial— Other yf 5 Number of living units: �= Numbe f be- droo� Wafer table depth Ovc%et'�r 6v� rb �l -..r-- Character of soil to a depth of 3 feet: Capacity,�� No. Compartments I SEPTIC TANK' ❑ Type/Mfg / / Method of Dispps �. p y q PKG. TREATMENT PLT. Q O Foundation Property Line s I! Distance to nearest: Well Total length!size i LEACHING LINE No. & Length of lines PropertyLine -5 -- I FILTER BED ❑ Distance to.nearest:.�fWe1 - Foundation_ –�- Number SEEPAGE PITS ❑ Depth Size Foundation Property Line SUMPS [I Distance to nearest: Well _ DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Jloaq uin`�n, ordinances, state laws;,an rules and regulations of the San Joaquin Local Health District. �4i -,-m i ensation laws of Calrfornia. C,5' ing or sub-contracting signature Home owner or licensed agent's signature'certifies the following: "I certify that in the'performa_nce 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 comp-_. 'sons subject to workman s compensa ! certifies the following:"I certify that in the performance of the work for which this permit+ slued,I shall employ f tion laws of California." The applicant must call for all required inspections. Complete drawing on revs seside. 7 _ Title: Signed .01 'ir,V,rw FORpEPARTMENT.I3SEONLY Date Application Accepted by pate Date `f.� e Final Inspection by� Y ` -Additional Comments: ' ❑ ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 + vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 Stk 466-6781 01 Applicant- Return all copies to: En PERMIT-NO,FEE CASH RECEIVED BY DATE AMOUNT OUF AMOUNT REMITTED INFO S + EH 13-24(REV.1/65) - 0 ' EH 1426