84-652 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT !I SAN JOAQUIN LOCAL HEALTH DISTRICT " 4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 J PERMIT EXPIRES 1 YEAR FROM MATE ISSUED r (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. w f , Job Address 1� ,j,{ City Lot Size - G pM Owner's Name _.e°A: yT � �%%X Address _ _A9/^O'C i ii �' Phone Contractor's Name License No. Phone + 7 { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �4 PUMP INSTALLATION ❑ ". _ 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 r g ❑ Industrial i El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing • Domestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other'. EJ Delta Depth of Grout Seal type of Grout ❑ Irrigation �JApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done i O Type'!of Pump H.P. State Work Done Well Destruction ❑ Well'Diameter `-"' Sealing Material (top 50') d Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION q (No septic system permitted if public sewer is r- !� �� . available within 200 feet.) Installation will serve: Residence� Commercial' Other r Number of living un is: _ �� ` _. I - 9 _._� Number of bedrooms�, � Character of soil to a depth of-3 feet: i s Water table depth Q SEPTIC TANK ✓ Type/Mfg7 Capac1ty_/1-Cf ICJ No. Compartments .� PKG1 TREATMENT PLT. ❑ !� h ! e F Method-of Disposal A Distance to nearest: Well c� Foundation_ l _ Property Line C3 f LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well: -� Foundation 0 Property Line E u w SEEPAGE PITS VDipth -2 f Size { Number SUMPS ❑ Distance to nearest: Well�[M P Foundation-f 0 . =}-_Prop arty Line 3� t DISPOSAL PONDS" ❑ x I hereby certify that I have prepared this application and that the work will be done in accordance with;San Joaquin county ordinarices, state laws, and rules and regulations of the San Joaquin Local Health District. i ; 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-per.mit-is-issued;-Lshallsmploy-persons subject to workman's compenisa- tion laws of California." The applicant must call for Al required inspections. Complete drawing on reverse side Signed s 1 Title.-- ; .. + - ..� 'p Date: ! �r ! FOR DEPARTMENT USE ONLY •+ s T f i Application Accepted by Date � 'ZE "�� Area 1 1 Pit or Grout Inspection by ateFinal Inspection ..+� s Date Additional Comments::.' I ❑ Stk 46&6781 i r.IJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83541385 Applicant- Return all-copies•to:-Environmental-Health•-Permit/Services-1601-E-Hazelton-Ave 'P-O,Box-2009;-Stk.,CA-95201FEE -= INFO AMOUNTgDUE. AMOUNT REMITTED" CK RECEIVED BY, CASH'] DATE PERMITLNO. + EH18-241RE'V.70/831 1}.yl (- i {',^ Rq� � � ' 4sa EH 1V[ ✓ y� NJ