84-368 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT SAN ]OAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1p� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j i Application is hereby made to the San Joaquin'Local Health District for a permit to construct and/or install the work herein L described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump P and the Rules and Regulations of the San Joaquin Local Health District, Jab AddressJ577 $[7.isf vision Name Owner's Name Address 15777y. i Phone _k— Contractor's N e4t-x. License No. 7—,06 0, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v' 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation i Domesticii—iv—t-eGravel Pack ❑ Tracy Dia. of Well Casing r e ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Cathodic Protection Depth Specifications ❑ — Depth of Grout Seal ❑Geophysical LJOther Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done .,Ilt-tL Gtl...owe Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') I� TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 1 available within 200 feet.) 1111 Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property line DESTRUCTION El h LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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 5ha1T not employ any person in such manner as to become subject to workmanS 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," I The applicant must gall,—Jr all required inspections. Complete dra#yng on reverse side. Signed x , Title: Date: Application'Accepted by!/I� FOR DEP ENT N Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Sym Manteca 823-7104 Final Inspection by Date r j�Tracy 835-6385 Applicant - Return all copi o: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO r , s r S Oa 4j £H 13-24 REV. 10/82 10/82 500 14-26 �C1Z�p