84-457 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 r 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. II '`�" 1 Job Address 1 3 u City y �� Lot Size 6� x t p PM rOwner's Name O �' 't' Address (3 V3 , V Phone Sl� r Contractor's Name_ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , —PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ � '" OTHER ❑'— DISTANCE TO NEAREST: SEPTIC,TANK. 'SEWER LINES DISPOSAL PLO. PROP. LINE ' I—FOUNDATION �4 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private W © Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other r ❑ Delta Depth of Grout..Seal.- _ Type of Grout " ❑ Irrigation a4 --.Approx. Depth ❑ Eastern Surface Seal Installed by A �- Repair Work Done ❑ Type.of, Pump H.P. State Work Done ' A * r Well Destruction., ❑ Well Diameter Sealing Material (top 50') a Depth - Filler Material (Below 501} Cu { TCYPE"OF-S"EPTIC WORK:-NEW INSTALLATION01,-RF-PAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is W it + available within 200 feet.l Installation will serve: Residence— Commercial_ Other Number of living units: rNumberzof;b { Character of soil to a depth of 3 feet: ¢ Water table depth yv I I SEPTIC TANK `0 Type/Mfg P Sr- -`F Capacity No. Compartments PKG. TREATMENT PLT."❑ 1, 41 Method of Disposal n a Distance to nearest: Well Foundation Property Line LEACHING LINE "' ❑ No. & Length of lines Tal length/size, S X a-D C FILTER BED : F Distance to n �earest: Well Foundation 14 Property Line -•� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: - Well Foundation Property Line to DISPOSAL PONDS Cl 1 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."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 tion laws of California." Jf t S F The applicant must call for all required inspections. Complete drawing on reverse side. " Signed X �era__g_ Title: `^ Date: -� FOR DEPARTMENT USE ONLY t Application Accepted by C 7_31_ _- Date 4- Z Area 7 � Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Irracy 835-6306 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT NO. "INFO 3%1 jCASH /o ` + EM 13-24IREV.10/33) y C-�..5. a —1 Z_ l '!'--" 1 C� S7 I �/\ O