85-1121 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT 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) (73_ 350 -3D 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. _ _ems^>.-. . �. Job Add Tss � /� 21- / U fLi-►-J! I`!'_ O G City Lot Size �— PM CoA.-sem �u�c �- o� at,&y,. qq� Owner's Name Address S(y}�� +� C��. _ Phone ---� ,1 Contractor �r u'�-O DDS •Address S �9-( iF. 5-J Si'iGN License NoA Z7 (7 Phone d-&�6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL'- " - "OTHER WELL PITS/SUMPS INTENDED USE'. TYPE OF-WELL PROBLEM AREA--CONSTRUCTION SPECIFICATIONS-^. "' Li Industrial _ ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of WeIlrCasing. _ Domestic%Private .f ❑'Giavel Pack 0 Tracy Type of Casing Specifications F ❑ Public ❑ Other 13 Delta Depth of Grout Seal Type of Gou# ❑ Irfigat`ioq ,; ---Approx. Depth ❑ Eastern R Surface Seal Installed by F Repair Work Done ❑ Type of Pump H.P. i State Work Done 6 V Well Destructs Well Diameter, ealing Material [top 50') �Z Et r�4' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system.permitted if public sewer is �. � ---t r� \.. :1 r a J ilable within 200 feet:ll Installation will serve: Residence____ Commercial Other i Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑' Distance to nearest: Well Foundation Property Line s SEEPAGE PITS ❑ Depth ' Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have preparedithis'applicallon 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 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 Ia allfornia." The ap icar t ust call f It required inspections. Complete drawing on reverse side. Signed Title: Date: c7 to FOR DEPARTMENT USE ONLY -��cF G Application Accepted by Date Area Pit or_Grout Inspection by DateFinal Inspection by M. s .. .. pate ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH1&24 4REV.1/e 6) `� { EH 1426 - A