85-211 - Laserfiche WebLink

Home Browse Search

_ k66 APPLICATION FOR PERMIT 4; SAN JOAQUIN LOCAL HEALTH DISTRICT n 1601 E. HAZE T ON AVE., STOCKTON, CA 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 Rules and Regulations of the San Joaquin :Local Health District. Job Address� w �� I City Lot Size PM Owner's Name Address �3 -�'+� Phone 3Cog` -7 1 / 'Contractor's Nam License No. �-712ffd.a G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public!l ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 6 Repair Work Done ❑ Type of Pump H.P. State Work Done 6 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth '� Filler Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION'El REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is j !// available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: –I-- Number of e room ; Gj ' Character of soil to a depth of 3 feet:_. � `' --- -----�-—Water table-depth- --,1 ----� SEPTIC TANK ❑ Type/Mfg °Capacity � No. Compartments PKG-,TREATMENT PLT. ElMethod of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE . f$' No. & Length of lines � r/�4 6 Total.le g h,/size O X o� f ,.FILTER-BED ❑' 'Distance to nearest: Well 53) Foundation /Q ,Property Line " SEEPAGEMITS Depth Size 3 r �" Pumber_ �, s SUMPS El Distance to nearest: Well XI) Foundation"�C Property, Line, •, DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be dog'e'p accordance with San Joaquin county ordinances, state laws, and rules'.and regulations of the San Joaquin Local Health District. j \' Horrie•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 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:"I certify that in the performance of the work for which this permit is issued, I shall employ Wisons subject to workman's compensa- tion laws of California." � I The applicant ust call for py reuired inspections..Complete.drawing-on-reverse e: . -�- -.� --t - --' .•T T i SignedX Title:, ,� Date: I •�� 4 r FOR DEPARTMENT-USE;ONLY ` + J, 1 Application Accepted by �� 37 Date / Area / or Grout Inspection by tion ate _3�� Final Inspecby Date $ Additional Comments: ; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83516385 Applicant_Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE " AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH +E14 13-24[REV.101631 EH 1426 I