85-1319 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 a�ddd ✓c- Y�SrY AL,4ety R/ - City 4$C-64/eye ' Lot Size A:57_4C-_y6s PM Owner's Name �]�W Address 54 Phone Contractor's Name /v� N 2e' 45�pIV License No. -!Z59r_:r # Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L1. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom k ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ; RA ❑ Tracy Type of Casing Specifications ❑ Public I ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i h ❑ Irrigation ---Approx. Depth ❑ Eastern . Surface Seal Installed by 6 Repair Work Done ❑ ' Type of Pump H.P. State Work Done -Well Destruction ❑:i, Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) G I Installation will serve: Residence X _Commercial_ Other Q i Number of living units: _. *Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK M Type/Mfg .—ppC CapaciNo. Compartments PKG. TREATMENT PLT. ❑ p. ,"3 ,6 4 ( G 1 Method of Disposal !r } Distance to nearest: Well 300 Foundation I d ` Property Line «"p' LEACHING LINE ®' No. & Length of lines # {�.wed% ' Total lerigth/size O _M . FILTER BED ❑ Distance to nearest: Well 3 d a Foundation /o ' Property Line J SEEPAGE PITS j/f El Depth / Size -V 4X Number �- t. SUMPS U[ 19 Distance to nearest: Welles a' Foundation` Property Line ' i DISPOSAL PONDS ❑ it + 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. s� 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 i 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 persons subject to workman's compensa- tion laws of California." `k The applicant must tccall l—for all required inspections. Complete drawing on reverse side.a f r iY t Signed X �r�.�. CSZ1C' Title: ' f Date: j FOR DEPARTMENT USE ONLY b �c• i / y t: Application Accepted by If r Date ` 4 Area ®� Pit or Grout-inspection b �,f 1 Dat Final Inspection by DatV Additional Comments: f�I.�YJ 86678 -❑-Stk w 41 El -- ❑ Lodi •369-3621 Manteca 823-7104 ' ❑ Tracy 835-6385- Applicant 35-Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.- Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED- CASH RECEIVED BY DATE PERMITNO. .v. + EH 13-24(REV.10/83) "T EH 1428 J {