85-259 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 PERMIT EXPIRES.I YEAR FROM DATE ISSUED 'TM .r (Complete.in Triplicate) i \,Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri described. This application is l node 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. y �_o-r - (9,o= , Re ca-7�/, Below Job Ad ss - Si...WS Y �� l_ _ 1 City. NGT ,Lot Size_ 7"� PM 1`17 z-- Owner`s;Name,_�TRC/f /a.Arpe71 Address - - - Phone YY- - V-2'/3 Contractor'NameG' rA At o •• License No. —�y� 89/ Phone s TYPE OF'WELL/' UMP: NffW WELL l3 WELL REPLACEMENT Cl DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSiSUMPS _ INTENDED USE )WPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indust ial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel.Pac\D�epthD Tracy Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.; Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction ❑ Well Diameter ��. Sealing Material (top 50') Depth '- Filler Material (Below 50') 0 TYPE OFjSEPTIC WORK: NEW INSTALLATION 2r, REPAIR/ADDITION El DESTRUCTION F] (No septic system permitted if public sewer is iP �v available within 200 feet.) installation will serve: Residence./_ Commercial OthdL - Number of living units: l Number of bedrooms Character of soil to a depth of 3 feet: XA&L� D Water table depth SEPTIC TANK Type/Mfg �@ CAPf G•d�t:��Ca aci BOO P tY� No. Compartments PKG. TR�TMENT PLT. ❑ : Method of Disposal Distance to•nearest: Well /40 Foundation�.J @' Property Line LEACH NG LINE F1 No. & Length of lines "" �O - Y Total length/size X 90 rn FILTER 8ED ❑ Distance to nearest: Well /O Foundation X T' " Property Line SEEPAGE PITS ❑,�Depth Sizer �`'V4 umber , SUMPS ❑ Distance to,'hearest: Well-----r/Foundation S I Property line n; . DISPOSAL PONDS 17r—,.Property I hereby certify that I have prepared this application and that the work will be done in accordance:wil Joaquin county ordinances, state laws, and rules andfregulations of the San Joaquin Local Health District. m n Home owner or licensed agent's signature certifies the following: "I certify that in the performance f he work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."'.dontractors hiring or sub-contracting sigature certifies the following: "I certify that in the performance of the work for which this permit is issued, !shall emn ploy�persons subject to workman's compensa- y tion laws Iof California." The applicant mus all for all required inspections. Complete drawing on reverse side. Signed Title: Date: y`/3 'BX \ FOR DEPART ' NT USE ONLY } �h tt Application Accepted by \ Date .7 "`��—�-� w ®� Area Pit or Grout Inspection bye+_t Date Final Inspection by + pat, � '- 4 fi d itional Comments:,,- Stk 466-6781 ❑ Lodi 369-3621 i j El Manteca 823-7104.E_ _[],:Tracy 83x6385 Applicant--Return all copies to: Environmental) ealth.P.ermit/Services 1601 E. Hazelton Ave.,� e, P.O. Box 2009, Stk., CA 95201 , } FEE AMOUNT DUE AMOUNT REMItTED:� SCK " ( INFO CASH RECEIVED BY DATE PERMIY'No. 6 � , +EH 13-241REV.101931 I -i..-. t EH 1448 k