85-1191 - Laserfiche WebLink

Home Browse Search

q� APPLICATION-,FOR PERMIT "- SAN•JOAO,UIli CAC HEALT1+,DISTRICT=., 1601 E. HAZE.TON�AVE., STOCKTON, -CA x" 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 well/pump and the Ryles and Regulations of the San Joaquin Local health District. " • ` �' "' Lot Size PM City Job Address > Owners Name Address Phone Contractor Address P, 'License NPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 11 Industrial Ll Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal x Type of Grout a L1 Irrigation ;y w ��4pprox. Deptfi ❑ Eastern Surface Seal Installed by Y' hf. Repair Work Donef;❑�,.Type of Pump H.P. State Work Done Well Destruction ❑,:";Well Diameter .Sealing-Material-itop 50'i � f`i ' _ p Fill r Material IBelow 501 TYPE OF SEPTIC WORK: NEW IN7Commercial TION REPA R/ADDITION DESTRUCTION ❑ (No septic"system permitted if public sewer,i's i. -�x available within 200 feet.} Installation will serve: Residence _ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 'ype/Mfg Capacity) No. Compartments PKG_, TREATMENT PLT. r7r I Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE X No. & Length of lines Total length/size ! A FILTER BED El Distance to nearest: . Well Vn Foundation Property.-Line' SEEPAGE PITS,-., f ❑ 3 Depth Size Number SUMPS di.t}Distance to nearest: Well Foundation Property Line DISPOSAL PONDS y Fx 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: •'t 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." i The applicant must call for a requir specti ns. Complete drawing on ravers id se. 4 Signed Title: Date: FOR DEPARTMENT USE ONLY Z Application Accepted byr Date ! Area j f I 1 Pit or Grout Inspection by �- Date I � , Final Inspection by Date t� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 u Manteca 823-7104 ❑ Tracy 835-6385 __ F Applicarit Return all copies to: Environmental Health Permit/5en+ices 1601 E. Haielton Ave., P.O-Box 2009,-Stk.,CA 95201'' FEE AMOUNT DUE AMOUNT REMITTED11 CK# -RECEIVED BY DATE PERMIT'N0. INFO CASH'. } + EH1s-24MEv.1ie5r EH 1426