84-906 - Laserfiche WebLink

Home Browse Search

.. .,.,,1,1 --�A►r-rim-ra.sit:-+Mlls,a!�xia./*�'r.�-.*?,'.fi,"�;^e�. �r r--a, W APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 — 1.�1 I (rrf— pe !/ �� w Ci �7j�/v IL �7Z 1O O t1' 7- Lot Size PM Owner's Name dress f Phoney '7 11A Contractor's Name License No. TYPE OF WELL/PUMP: Phone : NEW WELL O WELL.REPLACEMENT ❑ DESTRUCTION ❑ ' "�"''�PUMP INSTAL-INSTAL � ` t—SYSTEM RI PAIR`0 t DISTANCE TO NEAREST:-SEPTIC TANK-- C,4 t� R� � ' "OTHER-8 -- - SEWER-L-11 ES ___5" - DISPOSAL FLD. PROP. LINE FOUNDATION '' AGRICULfURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y4: ❑ Industrial ❑ Open Bottom :T Manteca Dia. of Well Excavation ❑ Domestic/Private" 4.❑ Gar vel Pack x 1` '❑ Teac� Dia, of Well Casing Y , Type of Casing Specifications ❑ Public ❑ Other -7— ❑ Delta Depth of Grout Seal 1 ' �� Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H P ; Well Destruction El Well Diameter �j State Work Done Sealing Material (top 50') , eA Depth 1� -. Filler Material (Below 50') TYPE OF SEPTIC WORK:f NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: 'Residence_ Commercial— Other l x Number of living units: 'Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welf Foundation Property Line r LEACHING LINE ❑ No. & Length of lines FILTER BED El Distance length/size Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS F1Property Line - yy� 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 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."Contractors 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 tion laws of California." p Y persons subject to workman's compensa- tion The applicant cal or,4 re ions. Complete drawing on reve Signed Title: . - Date: FOR DEPA TMENT USE ONLY Application Accepted by "` v Date 1 8 Area a Pit or Grout inspection by DateFinal Inspection by Date Additional Comments: N ❑ Stk 466-6781 ❑ Lodi 369-3021 O Manteca 3-7104 �T= 83 Applicant Return a!!copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK INFO `CASH RECEIVED BY DATE PERMIT"NO. + EH 1324(REV,101631 EH 1428 Sos