85-516 - Laserfiche WebLink

Home Browse Search

I f APPLICATION FOR PkRMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone(209) 466-6781 PERMIT EXPIRES 1 YEAR;FROM DATE ISSUED -' (Complete in.Triplicate) Y„ 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. . 'ate •! 1,,vL ;v;, - . .a . w /' ��' Job Address� ��- �' l�Y f�YQU rft City° rr1 Lot Size PM Owner's Name t 1 1"� 1 -Y1��_ Address .-. .G ne Contractor Address License No. Phone 7 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INST TINOO _ ? SYSTEM_REPAIR ❑. � RFG+THER,.11.� DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. t'.PROP. LINE 1 FOUNDATION A LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS - t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of We vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /❑ Public ❑ Other ❑ Delta Depth ofiiGrout-Seal Type of Grout t ,�❑1Irrigation 1 1 __._ Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of PumpH.P. I State Work Done / Wel! Destruction ❑ Well Diameter Sealing Material hop 501 ' Depth Filler Material (Below 50') ✓ "J.r 1 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence Commercial_ Other Number.of living units: Number of bedrooms 2 ._ Character of soil to a depth of 3 feet: S Water table depth �,/SEPTIC-TANK ❑ Type/Mfg _ Capacty1'' � No. CompartmentsIf I PKG. TREATMENT PLT. 1-1L -- Method of Disposal Distance to nearest: Well Foundation Property Line v , LEACHING LINE No. & Length of lines — E _ Total length/size—..Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation? 1 A,1 ; s Property Line DISPOSAL PONDS ❑ j . i' 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, anc�j rules and regulations of the San Joaquin Local Health District. _ Home owner or licensed agent's signature certifies the following; "I certify that''m`the Orforrnance of the work'for which this permit is issued, I shall not j 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." t +y - � 4 i The applicant must call for III required inspections. Complete drawing on reverse side.,.,,-,: + Signed Title: Date: FOR DEPARTMENT-USE ONLY--.,-- , { Application Accepted by ---Date � � f•"`'�""""""� ! oZ! r O p�� Area Pit or Grout Inspection by Date Final Inspection'by Date Additional Comments: J e �Jl ❑ Stk 466-6781 ❑-Lodi 369-3621 ❑ Manteca 823-7104 ❑iTracy-835-6385 Applicant- Return all copies toi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. :Box 2009, Stk.. CA 95201 = � INFO AMOUNT DUE AMOUNT REMITTED FEE CK c i RECEIVED BY . DATE PERMIT`N0. + EH 13-24(REV.1/a5; EH-14-25