85-1544 - Laserfiche WebLink

Home Browse Search

a' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ! Telephone (209) 466-6* •wr r . i.,I•- .{.Vi,µ ti'! PtTt�.-. PERMIT EXPIRES 1 YEAR'FROM.DAE :ISSUED .� l k: V �t1�t.: . : �tryr_•w� (Complete in rTriplicatel} . t � . 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. " Job Address 5-:53 " 5' / -!V VA F71s'L�n. ' 4cov 1 : � :4"r r /�/ os City Lot Size PM • r , Owner's Name Address Phone Corltracto AddressLir cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER "❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' FOUNDATION AGRICULTURE WELL OTHER WELL 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 1:1 Public El Other ❑ Delta Depth of Grout Seal Type of Grout ❑Irrigation ---Approx. Depth ❑ Eastern _T Surface Seal Installed by j 6 Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I i Pg-available within 200 feet. Installation will serve: Residence Commercial_ Other: l; Number of living units: Number of bedrooms 9 Character of soil to a depth of 3 feet: I - Water table depth SEPTIC TANK ❑ Type/Mfg t Capacitv-----L No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal O" ? Distance to nearest: Well -Foundation. Property Line i �.-r LEACHING LINE ❑ No, & Length of lines r Total length/size r FILTER BED ❑ Distance to nearest:" Well A Foundation Property Line SEEPAGE PITS Ej Depth Size I"^" Number SUMPS ❑ Distance to"nearest: Well Foundation Property Line , DISPOSAL PONDS ❑ 4_ hereby certify that I have prepared this application and that the`worklwill be done imaccordance 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 inthe 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•comperisation 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 ie-issued, I shall employ persons subject to workman's compensa- tion laws of California." �" t, The app' a t must c 11 for all req"uir i pection Complete drawing on reverse side Signed Title: Date: r oC'` �� T`' FOR DEPARTMENT USE ONLY Application Accepted by (!V / 0 Q Date Area Pit or Grout Inspectionby ^ iDat Date Additional Comments Stk 466-678 ❑ Lodi 369`3621 S t"❑ Manteca ac " 835-6385 Applicant- Return all copi�eps, to: Environmental Health Permim�it/Services 1601 E. H/azelton Ave., P.O..Box 2009, Stk., CA 95201 ; �Cfc��Q// t2a f G'r✓ 'Lc�'O �� A L�, FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY " DATE PERMIT NO. INFO r + EH 14 2s 1REV.1/H sl 11-30 S`5'-