85-693 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 456-6781 PERMIT EXPIRESFI YEAR FROM DATE ISSUED (Complete.,in Triplicate) :n1 ,.. 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 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District. r 1 r *- 17, C. tel.Vim• - _ CI ` �'y LOt SIZ9 PM F Job Address ,fq C ty Owner's Name ALArVN Address e- Phone a _ -� Contractor's Name j License No. vimPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATIONy SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIGTANK _ SEWER LINES--•--- 191SPOSAL FLD.' PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHERfWELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECiFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications El Public Ll Other ❑ Delta Depth of Grout $eal'e .. Type of Grout ❑ Irrigation ----Approx Depth O Eastern- - - S ce S Istalled-kiy�- -• "� -- ---.— Repair Work Done ❑ Type of'PumpH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ry TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ DESTRUCTION ❑ {No septic system permitted if public sewer is I f' available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3feet:; Water table depth SEPTIC TANK ❑ Typet/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. F-1Dista of Disposal i Distance to nearest: Well Foundation Property Line F — LEACHING LINE ❑ No. &.Length of lines Total length/size FILTER BED El Distance to nearest: "'Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number r i SUMPS ❑ Distance to nearest: Well Foundation Property Line \, DISPOSAL PONDS ❑ hereby certify that I have prepared Ais application and that the work will be done in accordance with 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 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." i , . The applicantimust call for all17i1 r Ins ctions. Complete drawing on r erse side.C,f- —'��(�a, Date: Signed Title: r } � � FO�DEPAR�TENT USE DNLY qf. Application Accepted by Date Pit or Grout Inspection by Date inal kspection by Date ;F Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 :Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009,.Stk., CA 95201 { t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEIS BY' DATE' PERMITNO. INFO CASH +EH 13-24(REV.10/83) EH 1428 _ -