85-1178 - Laserfiche WebLink

Home Browse Search

APPLICATION F T OR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZET O,N AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROWDATE 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. f1 Job AddressWZ25 P,.A; — City*L AJ Lot Size PM Owner's Name N SAALD 6: . A€e. :".Address $/.2/ J0'1W44W73r AIAV _3WAO Phone Contractor FLP$+P $. OVAO01 Address 1), ftR.� LicenseNo. a�-Z_Phone 444`397Z TYPE`OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J � PUMPANSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .:d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `– ----•-.-,.EOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other E-1DeltaDepth of Grout+Seal Type of Grout ❑ Irrigation ',_Approx.'�epth 171 Eastern Surface Seal Installed by Repair Work Done 1 ❑ " Type of-Pump H.P. State Work Done Well,Destruction . i ❑ Well Diameter Sealing Material atop 501 4 :, : --1 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.) N l I4) Installation will serve;( Residence_ Commercial� Other Number of living units ' Number of bedrooms 1 i Character of soil to a de f 3 feet: _ f f �. Water table depth ep SEPTIC TANK `/' "= Type/Mfg Ca aci )? t� P tV – No. Compartments PKG- TREATMENT PLT. ❑ i Method of,�Disposal s Distance to nearest: Well 'A 920 _ Foundation Property Line'I4- LEACHING-LINE' No. & Length of lines 2- B-P G � 9 � _ - Total length/size �� 'X �- � FILTER BED ' 1 El 'Distance to nearest: _Well= "Foundation Property Line SEEPAGE PITS ❑� Depth d _Size -Z, i Number 'SUMPS '3 kr�Distance to nearest: Well Foundation Property Line A& 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 I rules and regulations of the San Joaquin Local Health District. 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 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." , I The applican�Calll uirad ins pec' S. Complete drawing on reverse side. Signed Title:= c Date: 4 `? FOR DEPART ENT USE ONLY Application-Accepted by ' Date Area C l> . Pit or Grout Inspection by Date Final Inspection by QJ4a: i " pate b .� r Additional Comments: ❑ Stk• 466-6781 /. ❑ Lodi 369-3621 ❑ Manteca 821-7104 ❑ Tracy 835-6385 Applicant Retti m all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '^ CK 0 INFO AMOUNT DUE AMOUNT REMITTED "CASH RECEIVED BY DATE PERMIV NO. + EH 1324(REV.1/8 51 ._ „` 6S AREH 1426 u i