85-959 - Laserfiche WebLink

Home Browse Search

I - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA .._ Telephone (206) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Pi .> .. + (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 Local Health District. . - c I S f V , G City �Ii�1 L'ot Size y PM ,fob Address I Owner's Name �Q1'1 � — Address Phone Contractor's Name ' /ZA` )cense No. 7W 1.571Phone R, + .TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOR� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. !_0 PROP. LINE 2_0 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rGb-&. _ INTENDED USE >` TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' t et •PC3-Industrial --- --=►J�Open-Bottom Ir Q-Manteca—�--•Dlaaof Well-Excavation Dia.,of Well-Casing i 19 Domestic/Private ❑ Gravel Pack ❑ Tracy I Type of Casin Specifications a to I 0 Public ❑ Other ❑ Delta t Depth of Grout,Seal' S'01 Type;of Grout ❑ Irrigation _. Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ,H.P. s State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 1� l Depth Filler MateriaH8elow=50+ � # Ii` r TYPE OF SEPTIC WORK-: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t :1 available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of'living units: Number of bedrooms .. ✓. Charactat'of soil to a depth of 3 feet: 1 e -Water table depth SEPTIC TANK ❑ Type/Mfg •' _�- CaOaccity No. Compartments PKG. TREATMENT PLT. . Method of'Disposal r • Distance to nearest: Well Foundation 3 Property Line 't f LEACHING LINE ❑ No.'&%Length of lines �'�* -� "� Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation i Property Line s /� SEEPAGE PITS I ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property JLine DISPOSAL PONDS ❑ __. - ---r + hereby certify that I have prepared this application and that the work will-be ddi a in accordance W!tK San'Joaquiri county ordinances, state laws,-and— k rules and regulations of the San Joaquin Local Health District. t 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 S 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 shalt employ'persons subject to workman's compensa- tion laws of California." i N'`'+ The applicant call for all require d inspections. Complete drawing on reverse side. r Signed X Title: A , Y`' Date: FOR D PARTMENT USE ONLY ` Application Accepted by Date Area it r Grout Inspection by Date Final Inspection byO-ZDate .. �rI-yam. Additional Comments: J j FI 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 AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 tREV.101831 EH 1426 -