85-1530 - Laserfiche WebLink

Home Browse Search

F .N ` APPLICAT.ION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA one (209) 466-6781 Tefe h ., PERMIT EXPIRES 1 YEAR FROM DATE ISSUED vxw.r (Complete in Triplicate) /or install the work cation is Application is hereb made Sanothe JoaquirinCountynOrdinalnce Nto.District549 for sewage or permit 1862 for cwell apump and the Rules and IR Regulations of he Sari 1 Joaquin made in compliance ;t + Local Health District:" City. Lot Size i 4 PM Job Address e ' _ _ j � .ZAddress `\ Phone �-9zrL�L,f �'�: Idfo1�C k Owner's Name Address License No.Ji/T��--Phone Contractor INEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ElTYPE OF WELL/PUMP: OTHER ❑ _._ PUMP INSTAL-G4TION--E] SYSTEM REPAIR ❑ 6, SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL ' { i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ❑:Open Bottom: -o- ❑ Manteca = . Type of Casing Specifications ❑ DomesticlPrivate ? ❑ Gravel Pack ❑,Tracy yp Type of Grout � 1 ❑.Other 17,.Delta Depth of Grout Seal t [3 Public [I irrigation .,�pprox. Depth ❑Eastern Surface Seal Installed by f -1 H P State Work Done , { I 'Repair Work Donee Pump O Type of Pui i ` '• r Sealing Material (top 50'1 Well Destruction ❑ Well Diameter Filler Material (Below 50') * ': I Depth ' TRUCTION '[No eptic system permitted if public sewer is EW INSTALLATION ❑• REPAIRIADDITION ave ble within 200 feet.) , r TYPE OF SEPTIC WORK: N ( Installation will serve: Residences Commercial Other Number of living units: ' Number of bedrooms Water table depth + E , Character of soil to a depth of 3 feet: # Capacity No. Compartments ISEPTIC)TANK,.",. .-- ❑, ',:Type/Mfg— Method of Disposal PKG. TREATMENT PLT. ❑f f' jProperty Line Distance to nearest: Well Foundation s t",�, Total length/size k LEACHING LINE ' ' ❑ No. & Length of lines AMFoundation Property Line ,FILTER BED ❑', Distance to nearest: 1111E11 - "s +; SEEPAGE PITS ��❑' Depth Size Number 1Property Line" SUMPS ❑ Distance to-nearest: Weil Foundation DISPOSAL PONDS ❑" 1 hereby certify that I have prepared this application and that the work will be donexin 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 l employ any person-insuch_manner_as to become subj®ct to_w9rkCORn_s compensation laws of Califprnisubject to workman's compensa a. 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 tion laws of California." The applica ust call fq�ll`required ins ct�s. Complete drawing on reverse side. r Title: Date: Signed X F ! OR DEPARTMENT USE ONLY Date ea Application Accepted by Pit Grout Inspection by Dae Final Inspection by Date �r f XAp tional Comments: 7104 ❑ Tracy 835 tk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823 6385 plicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUN DUE= AMOUNT REMITTED RECEIVED BY DATE, PERMIT'NO. INFO = + EH 13-241REV. - _EH 1426 i