85-280 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT .v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED t . (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. \ y� -7 Job Addre �I`FJ �l 1-1 L Ey,-. � r City `� tt SizeZtft / PM 7-1 Owner's Name 1 Address --Phone- Contractor Let-' k)K L7' W-Address License No. .. Phone /� E 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 I t� -.INTENDED USE. — TY.PE.OF WELL-_.s...PROBLEM.AREA_...,.CONST.RUCTION.SPECIFICATIONS - _ _ - •-, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑,Gravel Pack _ ❑ Tracy Type of Casing i # Specifications ❑ Public ❑ Other _r ❑ Delta Depth of Grout-Seal - '-"' "" Type of Grout-- Er' rout-- t .❑ Irrigation+u 7( �Approx.#Depth ElEastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r + Well Destruction ❑ Well Diameter_ Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 111.�-REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - ' , available within 200 feet.) Installation will serve: Residence 1- Commercial_ her y I Number of living units:--J— Number of bedrooms a a . Character of soil to a depth of 3 feet: Water table depth -5, ) SEPTIC TANK 09--Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -;,.. r' Method of Disposal Distance to nearest: Well a Foundation Property Line � E LEACHING LINE C9.—No.^&-Length-of lines - Total length/size " FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS Depth DS Size C0 Number ! SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. ,-k .a 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, I shall not employ-any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or-sub-contracting signature certifies the follow . "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-, ramie awr.s of California." The app i must call f all uire in pectio s. Complete drawing on r verse sid Sig itie: i Dat f �� OR DEPART E ONLY �-A iicatian Acce ted'fi PP p Y.___r_..,r -` .r,r,,,,:_ "-"". � - - "Date � Area to i 17'mss � }'� Pit or Grout Inspection by Data Final Inspection by - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ""Applicant-=-Refurn all"copies to:Efi i46nmenial`Heiltfi Permit%Services 1601 E..Hazelton Ave.; PzO. Box2000, Stk., CA 95201 F FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEp PERMIT NO. +EH 13-24 1REV.1/05) 4�-O° EH 14-M 1 f V