85-53 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELI ON AVE.,;STOCKTON, CA , Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROMIDATE ISSUED. (Complete in Triplicate) 2 . it to construct cation is Application is herebyma e to the San Joaquin n County 0 diva Health istrict for a No.549 for sewage or No. 1862 forwell/pump aYall herein nd the Rules and R Regulations r of he SanJoaquin made in compliance N ith San Local Health District... i �, Ci Lot Size. PM Job Address. _ _ = C,S�� II-GrK.E✓� Phone _ Owner's Name Address f at� � Phone Contractor's Nam �`A. �= License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRl1CTlON Q { PUMP INSTALLATION El PROP. REPAIR ❑ OTHER C1 ! iPROP. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �� �� UMPS FOUNDATION. AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ` E3 Industrial ❑ Open Bottom F-1MantecaDia. of Well Excavation Specifications , a Type of Casing ElDomestic/Private ❑ Grave! Pack ❑ Tracy; Type of Grout�"� ! ' Q Other i ❑ Delta Depth of Grout Seal ❑ Public ❑ Irrigation --Approx. Depth ❑ Eastern Surface Sea! Installed by r State Work Done Repair Work Done ❑ Type of Pump, H.P. Wel! Destruction 171 Well Diameter Sealing Material (top 50'} I 4 Depth Filler Material (Below 501 s TYPE-OF-SEPTIC-WORK: NEW INSTALLATION. - --REPAIR/ADDITION -9—DESTRUCTION ❑-aNailable�wi h within feet.).0 -.public sewer is ; .. �. Installation will serve: Re$idence Y�, Commercial_ Other I N v' Number of living units: Number o bedr Orris f' Water table depth Character of soil to a depth of 3 feet a Capacity a� ©O No. Compartments ` SEPTIC TANK Type/Mfg , Method of D'�posal PKG. TREATMENT PLT. ❑ w 'Distancetoto nearest: Property Line - ' Foundation •,,; Wel�� t ` Q _ Total length/size LEACHING LINE No. &Length of lines r I2K =-r FILTER BED ❑ Distance to nearest: Property Line Well Faurrdatm =}Q -. — tIf Size 1--J Number ,,--'SEEPAGE PITS - ❑ Depth �4 .1.1'. _. .z; SUMPS ❑ Distance to nearest: Well Foundation- Property Line DISPOSAL PONDS ❑ """ ordinances, state laws, and I hereby certify that f have prepared this application,and that the work will'be^done in accordance with San Joaqu n county �� rules and'reg ulations_of'the,Ssn Joaquin Local•Health-District.g + Home owner or licensed agents signature_certlfies_the_followin I certify that in the performance of the work for which this permit is issued, I shall not } employ any person n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work,for which this peimitis issued,I shall employ persons subject to workman's compensa- tion laws of California.,, The•applican ust tail r all requirediinspection Completed se' wing on reverside. ` > { Title: Date: C9 Signed s _ FOR DEPAFITMENT USE ONLY c� r % Area Date A Application Accepted by t i` Final Inspection by V Date Pit or Grout Inspection by Date + ^� ter, !✓� Additional Comments. 104 ❑ Tracy 835-6385 w ❑ 5tk 466 6781 ❑ Lodi 3W3621 O'Manteca Stk., CA Q__ Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box PERMIT"NO. FEEZj04UEAMOUNT REMITTED CASH RECEIVED BY DATE INFO mit _t_3 -S Y + EH 1324(REV.10/83F4"� _-- - S-'�--�••f` 1, EH W28 _ T