84-948 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT BIWA f .I, SAN JOAQUIN LOCAL HEALTH DISTRICT M JUL 2 71 ,\, c3 1601 E. HAZEL T ON AVE., STOCKTON, CA PIP Telephone (209)'466-6781 �t� +.�, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED #F�{.`� IL, MT wen,�'` (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 44-t 41 Y� .213 +2 4ol,� City ��-za Lot Size/ PM Owner's Name �k7�GlQ / �V +a� �"2� Address Phone ti Contractor's Name License Nol'i 16 Z 3� 7.3 Phone 466 T 6 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IM�i 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [I Public ❑ Other ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �` q Repair Work Done W-**'Type of Pump AW_7 7 H.P. State Work Done-Ate 11A ZJ n Well Destruction ❑ Well Diameter Sealing Material (top 501 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.) l Installation will serve: Residence_ Commercial_ Other Number of living units: Numbor of bedrooms r y Character of soil to a depth,of"3 feet: — Water table depth SEPTIC TANK p Type/Mfg Capacity No. Compartmer%t it PKG. TREATMENT.Fl-T.❑ Method of Disposal",-tti f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BEI ❑ Distance to nearest: Well Foundation Property Line SEEP E PITS E] Depth Size Number sum S ElDistance to nearest: Well Foundation Property Line DI POSAL PONDS ❑ IVhereby certify that I 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. I Home owner oriimnsed agent's signature certifies the following: "I certify that in the performarice of the.work for which this permit is issued, I shall not employ any p uch manner as to become subject to workman's compensation laws of California.''Contractors hiring or sub-contracting signature certifies th ollowIng: I ceriify-tha't in t perfor nee of the work for which this permit is issued,I shall employ persons-subject to workman's compensa- tion law of California. The iicant u al or ail r ons. Co ete drawing on-reverse-Sid �• _ _. Signe �' ~^ Title: Date: Application Accepted by Date Area Pit or Grout Inspection by �•+ Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104`''--.D Tracy 835-6385 Applicant- Return all copies to: Environment4 Health Permit/Service 160 Ha&plton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CC4K&H RECEIVED BY .,DATE PERmIT�NO. t + EH 1324{REV.10/631 7� 1428ry EH �� '�Y 1-1