85-298 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Joa in County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �,f► ��,�f �. '1 l Job Address 4111 f i„ �$Rr`i��r~S C7�v-,- City Lot Size PM Owner's NameJDC)4Cost, Address Phone Contractor's Name 1•�V_ License No. Phone TYPE OF WELL/PUMP: NEW WELL,❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEARE9T_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-ExcaVii on Dia. of Well Casing 7-1 _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-o-f Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done (IV Well Destruction ❑ Well Diameter Sealing Material (top 50') 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,) Installation will serve: Residence Commercial_ Other . Number of living units: Number of bedrooms Character of soil to a dept of 3 feet: Sc n 01 bG —Water table depth 1p SEPTIC TANK I"Type/Mfg A `I-' L Capacity — No. Compartments �"b PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line tw LEACHING LINE �Vo. & Length of lines k �� '"�� "'�g To aI gth/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k ' SEEPAGE PITS ❑ Depth Size Number - SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature certifies the fallowing: "I certify that in-the performance of the work for which this permit is issued, 1 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 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." The applicant must call for all require inspections. Complete drawing on reverse side. r Signed Title: Date:— R DEPARTMENT USE ONLY Application Accepted by ` =-Date Area if�� Pit or Grout Inspection by Date Final Inspection by Date/_/0 lr� Additional Comments: �^ t ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .:-- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E-Haz®Iton Ave., P.Q. Box 2009,-Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT"NO. INFO CASH + EH /2-7 JI- S. (REV.10/831 c pr EH 14-26 • Q �� / O .