84-75 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT SGN JOAQU2, LOCAL HEI.LTH D7 STRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to,the San Joaqui-n-Local Health District for a permit to construct and/or install the work herein r . described. This application.'i,s 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 ,]oaauiiLocal Health District. Jab Address_�Qn .. �.N040 `j A;/,/,L�i=_ Subdivision Name Owner's Name ,0 A) !J LY" Address 3 m2,3 S-s_. A,,d & .Phone PTA —2hV,_T Contractor'sName GLsati 10N/s License No. Phone 6`16—X7 r7 _ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U , PUMP INSTALLATION (] SYSTEM REPAIR OTHER U , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Wel] Casing ❑ Public Other Delta Type of Casing ��y LjIrrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout k U Other f Surface Seal Installed by n Repair Work Done Type of Pump sk H.P, f �'2J State Work Done 6,0 4a.0 P Well Destruction.❑ Well Diameter Sealing Material (top 50') C�l Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK M Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property line DESTRUCTION ❑ LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line ` k SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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 compensation laws of California. The applicant must call for all required inspections. Complete drawing on reverse side. . Signed X Title: L �i[.� Date:,. F DEPARTMENT USE ONLY �i--7 Stk 466-6781 Application Accepted by Area ff Additional Comments: [� Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 { Final Inspection by Date �" 7 - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmegfit Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FOBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ! PAATE�p PERMIT NO. 10/82 .500 EH 13-24 REV. 10/82 14-26 ,.