85-1486 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT G = 1601 E. HAZET ON�A-UE.;STOCKTON, CA �`T ` ea2epe,(09),,466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ar,, K 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 Joaqueaunty Ordinance No.549 for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. '`f � * City Lot Size' PM Job Address Owner's Name / ,5 / 69.19 Phone / f r, - r Contract t ^= ddress V / License No./CJ � / hone ,-4 TYPE OF WELL/PUMP . NE. WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION LlSYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP..LINE.` F FOUNDATION-- `"" —AGRICULTURE WELL" ' OTHER WELL` ^� "PITS/SUMPS— TENDED 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 = 3dType of Casing Specifications p Public -'Ll Other ❑ Delta r t Depth of Grout Seal ` Type of Grout i d - ❑ Irrigation ��4pprox. Depth` ❑ E stern `. Sue Seal Installed by Repair Work Done Lil Type of Pump H:P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 a Depth ' i ° Filler.Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available-within-200-feet.)r,_,,.. .� Installation will serve: Residence - Commercial �' Other ' Number of living units: Number of"bedroom's Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ...: I hereby cern ave prepared this application and that the work'will be done in accordance with San Joaquin county ordinances, state laws, and rules an gulations of San Joaquin Local Health District. i Home wner or licensed age is signature certifies the following: "I cerfify that in the performance of the work for which this permit is issued, I shall not emp y any person in such m nner as to become subje workman's compensation laws of California."Contractors hiring or sub-contracting signature ce !as the following:"1 cert that in the o he work or which this permit is issued, I shall employ persons subject to workman's compensa- tio laws of Caiiforn' .' at Th applicant u all re ire omplete awing on re r side. r el Signe Title: Date: - FOR DEPARTMENT USE ONLY A01rtiArea Application Accepted by C��- - Date x Pit or Grout Inspection by Date Final Inspection by Date .�u Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental With Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED. CK# RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 13-24(REV.f/85) EH 1428