85-385 - Laserfiche WebLink

Home Browse Search

P ' M Y f APPLICATION FOR PERMIT. . , SAN JOAQUIN LOCAL^HEALTH DISTRICT R 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone{209) 466-6781 .a 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 s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the,San Joaquin Local Health District. Job Address �Z��( N t'� City '-`�5�j'IVILot Size zlv�j PM i Owner's Name a�L Address Z7-C69- 13A :527-/1--lb ' Phone'.' JVV00 �q Contractor D� r Address -?]6c) A License No. Phone ` TYPE OF WELL/PUMP: NEW WELL VP`- WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK JOd 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 El Manteca Dia. of Well Excavation Dia. of Well Casing �mestic/Private 11d Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑— D`eo Depth of Grout Seal Type of Grout N 1:1 Irrigation �pprox. Depth astern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.- State Work Done µ._Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 3 available within 200 feet.) Installation will serve:^ Residence Commercial_ Other �"(> -N umber of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' .. „. `Water table depth SEPTIC TANK TypeiMfg �� Capacity 7�CSC) No. Compartments PKG. TREATMENT PLT. ❑ ' ' ' �. Method of DisposaI/ Distance to nearest: Well ItaU Foundation Priiperty Linrie LEACHING LINE , No. & Length of lines „Tota.l length/siie , FILTER BED ❑ Distance to nearest:-' Well Foundation- Property Line SEEPAGE PITS X Depths 2 Size 3 / Number ti SUMPS ❑ Distance to nearest: Well �OFoundation.l__ Property Line z DISPOSAL PONDS ❑ t e I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin Local Health District. . .+� \ =tea" '� 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." Contractor's hiring or sub-contracting signature certifies the foilowin :"'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 Calif is." The applicant t c/a�l�I for requi$ed inspections. Complete drawing on reverse side. ` - � Title: Date: 1 Signed+ - b- FOR`DEPARTMENT USE ONLY Application Accepted by v— Date Area D� Pit or Grout Inspection by Date F final Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .82;3-7104 ;.'❑]Tracy 835-6365 Applicant- Return all copies to: Environmental Health Pe mit/Services;1601 E. Hazelton,Ave., P.O. Bax 2009,'Stk., CA 95201 ... FEEr �# INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. � S , + EH 13-24{REV.i/s 5) ,„ _.-__ rA - EH 1426x, _