85-1365 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM 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 we and the Ryles and Regulations of the San Joaquin i Local Health District. •L` k I - Job Address W City Lot Size `' PM Owner's Name -- _ . . -�="-:-. ="'Address _ _ _ _ -- Phone' {{ 4 Contractorddress4o. e TYPE OF WELL/PUMP: Paw WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w FOUNDATION-,,^- --d-'--:AGRICULTURE-WEL-L--!-- -OTWER"WELL—� ^ ^"-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f / ❑ Industrial ❑ Open Bottom; 0.Manteca- _ Dia..of Well Excavation '' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '1 EITracy Type of Casing _ Specifications',. C ❑ Public ❑ Other X ❑ Cfelta . .,x; :Depth°of Grout Seal Type of Grout.. ❑ Irrigation ---Approx.,Depth " ❑ Eastern' Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 ` Depth L2� Filler Material (Below 501 k° TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if,public sewer istzl t `, available within 200 feet.) Installation will serve: Residence Commercial_ Other j r Number of living units: Number of bedrooms tj Character of soil to a depth of 3 feet:I d Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments z PKG. TREATMENT PLT. ❑ i� Method of Disposal Distance-to nearest: Well Foundation Property Line I, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance 4o nel rest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I 1. Size Number f SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this 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 ce#tifies the following:"'i certify tKat"in-the perfoirnance oftfie work f6r ltihicFi'this permmii�is issued, I shall not 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 shall employ persons subject to workman's compensa- tion laws of California." ; L The applicant must call for all require ins tions. Complete drawing on reverse side. A.Signed Title: n Date: Z04 �O O./ FOR DEPARTMENT USE ONLY t a Application Accepted by • ~r�{ y'� Date f Area I ; Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:` ❑ 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 CKV INFO AMOUNT DUE # AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. r Q + Eli 13-24 1 REV.1/0 61 i EH 1428 I V �� f �T.� IR-5- A