84-923 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMITA' 0 t SAN JOAQUlN LOCAL HEALTH DISTRICT 1601 E. HAZE4 T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED `Y n t�;,•. . ,(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 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. Job Address 79 2IP C f _,(}ZX /�� i T City. r Lot Size PM _ 1 Owner's Name Phone f Address"` - r 2 R Contractor's Name �A-'TLicense No. Phone - 0 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 f s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [IIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications t LLL EDPublic El Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done «. Well Destruction ❑ we Diameter Sealing Material (toW50') --• ` "" Y "- ^^ ` " Depth 3 Filler Material (Below ') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is } F—avaiiable-withhV200=fM1- i SM1 E Installation will serve: Residence V'Commercial_ Other � Number of living units: Number of bedrooms _ # Character of soil to a depth of 3. feet: P Water table depth SEPTIC TANK ❑ Type/Mfg A/Z Capacity' yy No. Compartments t ` PKG. TREATMENT PLT. ❑ i; p" Method of Disposal .. Distance to nearest: Well s��-__ Foundation_Z_0!._ Property Line -�4!? _ r LEACHING LINE No. & Length of lines 2 "' . —Total length/size FILTER BED ❑ Distance to nearest:- Well Foundation �_ Property Line_c SEEPAGE PITS ❑ Depth Size _ Number SUMPS ❑ Distance to•:nearest:* -Well, - ��Foundation�"' �__Prgperty-Line_i i DISPOSAL PONDS .-❑ � ' 1 _ f I hereby certify that 1 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 following: "I certify that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner-as to become subject to workman's compensation laws of California."Contractor's-fiiring 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 I ? i I I € The applican us call for all.requd ir ins ' ns. orrmplete drawing on reverse dem Signed X Title" itle --7 - Date: �3 FOR DEPARTMENT,,USE ONLY LIA plicat'on Accepted b ' Date 2 Area O ..,_ 5L C bYr Date Final'Inspection by ate i Additional Comments: I f ❑ 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 95201FEE e ; INFO AMOUNT/DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + fEH 3-24 H 1 (REV.1 1-7:27 4$i ��j•-° �.'C�,�y- �„/ ` -. C1 _ `✓