85-294 - Laserfiche WebLink

Home Browse Search

APPLICATION-FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209),466-67,81 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ,y *` (Complete.in Triplicate) Ap�ilicafion 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 o `Health.District. Lcal 7 a ""." w: CityX 0�- Lot Size. I PM Job Address Phone Owner's Name Address � �- 1 ty License No. T ' — ---- Phone Contractor's Name A ' HYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION ❑ i .UM INSTAt-LATVON"C� A.' SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-- 7 ELL PITS/SUMPS I * INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial Specifications I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 3 ❑ Delta Depth of Grout Seal Type of Grout # j ❑ Public ❑ Other 3[ ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by State Work Done r Repair Work Done ❑ Type of Pump H.P.Well Destruction ❑ t.W;-II Diameter Sealing Material (top 501 ; �/bepth Filler Material (Below 501 ` k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailableiwth ne200 er feettted if public sewer is C Installation will serve: r9 esicjpnce Commercial_ -Other F t �f _3 _ � + i Number of living ui-t..s umber of bedrooms.-3 Water table depth :5 Character of soil to a depth of 3 feet: ; yy., r- Type/Mfg Capacity 00. Compartments fb i SEPTIC TANK -,, g f ,�. N Method of Disposal # � a PKG. TREATMENT PLT. ❑ ' I-/ Distance to nearest: l Foundation roperty Line .' k nII LEACHING LINE No. & Length of lines i- � Total length/size k Property Line es A� FILTER BED ❑ Distance to nearest: Well Foundation— P .� i SEEPAGE PITS ❑ Depth m� Size ' ' Number - ❑ Distance to nearest: well j,, `'Foundation�' ©t" Pro erry'l irfa' T t �,ti SUMPS - `— = r i DISPOSAL PONDS ❑ dd �F I hereby certify that l have prepared this application and-that the work wi11 be done+n•accordanc$with San�oaq i_n,.county ordinances, state laws, and rules-and regulations of the San Joaquin_Lbcai Health District.- r* i Homeowner 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• ` person in such manner as to become subjeci to workman's compensation laws of fCalifomia." Contractor s hiring c sub contracting signature 1 employ any t cartifies The following: "l ertify that in the performance of the work for which this permit is issuedI,I shall employ Aersons subject to workman's compensa- f r V 17 tion laws of California." s* ` ,,.-: ; y; I TW6,-applicant must cat or I required ins 'cti ns. Compiete drawing on refyers side. .F, r r �' * ^moi; ! �-1 Data: Signed Title: r ' C O FOR DEPARTMENT USE ONLY ? Date ` Area I ;Apolication,Accepted by,, t '.� Dat - �rr Date Final Vnspection' '�-b � _. -,CPVt or Grout Inspection by,,.` i i Additional Comments: ❑ Stk 466-6781 ❑`Lodi 369-3611 © Manteca 823-7104 O Tracy -8354M ,,,,-Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazaltOny4ve., P.O. Box 2009y'Stk., CA 95201. t ` ¢ " CK RECEIVED BY DATE PER FEE CASH `NO. } . AMOUNT DUE AMOUNT REMITTED INFO ` r r_ �] �+EH 13-24(REV.10!831 t _EH 1,4.26�, J t,,.-