84-879 - Laserfiche WebLink

Home Browse Search

1 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r` 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... 3 � Cy Job Address __� � .�A�� ... Citp �c LZ}t'Size PM f aK Owner's Name _ �Z�� Address �� Phone Contractor's Name L—Y--= F L > icense No. Phone 77 Z5— ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ € __.—DISTANCE TO NEAREST:�SEPTIC TAMC __MSEWER LINES,,,•„ _ ____ ,DISPOSAL FLD. -,)?ROP. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done ^� Well Destruction ❑ Well Diameter Sealing Material {top 501—r Depth ____. Filler Material (Below 50') rRt TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION S -RUCTION ❑ (No septic-systern permitted if public sewer is available within'200 feet.} Installation will serve: R 'dance�Cfommercial' `Other Number of living units: Number o} bedrooms Character of soil to'a depth of3 feet: 2 Water table depth SEPTIC TANK 34'1pe/Mfg j _ _ Capacity Nor/Compartments PKG. TREATMENT PLT..-,D f Method of Disposal 3 - Distance to nearest: Well Foundation Property Line LEACHING LINE F &Len th of lines ! :` 9 Total length/size FILTER BED ❑ Distance to nearest: Well.- Foundation Property Line SEEPAGE PITS �th E=Size w Number SUMPS ❑ Distance to nearest: Wel IQ--Foundation4 _ P►ope`rty•Lirie DISPOSAL PONDS 17j { I hereby certify that I have prepared this application and that the work+mill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f _ �I r 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- tio f C canalifornia." ; t The applit call for requi insptins. Co plate drawing on verse std Sign Title: ftaC.G_�7 Date: �/ 1 / 1 FOR DEPAR ENT USE ONLY Application Accepted by Date rea C i Pit or Grout Inspection by �..Date ?7 Final Inspection by - Data %p 7 a `r r tn�l�Vcc/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 `l El((Aanteca s 7104 `� ❑ acy 835.63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave, P.Oil Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE ; = AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO.' U +EH 1324(REV.10193) 4/1") ! � 7/I gT�Z4-R7 q EH 14.26 4