84-995 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. , ,. , :y. w , . . ;, ..1. , Job Address +�S yr.5 �`i�'�5 h'¢'S' City rX�� Lot Size PM Owner's Name �✓ / ��' ,` �-^ Address �� ( Phone Contrac#or:l arne' 4 �G"V /'V G License No. - Phone TYPE OF WELL/PUMP: y NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `.-' VV DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ - PITS/SUMPS INTENDED USt TYPE OF WELL PROBLEM AREA CONSTRUCTION._SPECI_F]CATIONS � ❑ Industrial > ❑ Open Bottom ❑ Manteca Dia. of W6I Excavation IY pia. of Well Casing ❑ Domestic/Private, E] r Gravel Pack ❑ Tracy Type of-Casing . a Specifications i ;r El Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done O Type of Pump H.P. State-Wofk Done A Well Destruction ❑ Well Diameter Sealing Material (top 501 O� Depth Filler Material'IBelow 504 TYPE OF SEPTIC WORK: NEW INSTALLATION 1K REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system perrtiitted if public sewer is r t ,. available within 200 'Installation will serve: Residence L� Commercial_ Other I Number of living units: _Z-- Number of bedrooms ",.Character of soil to a depth of 3 feet: Water;table depth's C SEPTIC TANK ❑ Type/Mfg Ph Cz s T � ,Capacity /2270 No. Compartments PKG. TREATMENT PLT. ElMethdd of Distosal IIII I Distance'to nearest: Well /0D �4 Foundation' f '/o Property Line /D LEACHING LINE 1-1 No. & Length of lines Tyta length/size � FILTER BED 11 Distance&,nearest:, Well 100"At h Foundation•Property Line .r SEEPAGE PITS ❑ Depth Size Number y SUMPS � ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS , ❑ I hereby certify that I nave 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. �r_tw _t �/" Home owner or licensed agent's signature certifies the followiiig`r;1 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 lav/s,of-California.'-Cnntr oes hiring or sub-contracting signature certifies the following:"I certi t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of Calf The applicant s ca o fl req inspe ate drawing on reverse side. �. Signed X Title: )ate: FOR DEPARTMENT USE ONLYi Application Accepted by + Date � v {I Area W41 ' i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: l \A • e ` ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 8341'04 ❑ Tracy 835-6385 Applicant- Return all copies to: Environment I Health Permit/.Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITG'}NGO. + EH1324{REV.10/831 ¢ 1 (•r_. .,-,-• '`•- 1,��1 '/ �Y ! � r ! 1�.� EH 14-28 I