83-1290 - Laserfiche WebLink

Home Browse Search

w APPLICATION FOR PERMIT ' a. •� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 made in compliance with San Joa uin County Ordinance No.549 for sewage or No. 1862 for well/ um and the Rules and Regulations of the San Joaquin P ®� tY 9 P P g q Local Health District. Job Address � '"' City "" `�'r Lot Size 77 174ePM r� Owner's Name /Gr / /FwAddr /� /dT fi/r Phone O(3 Contractor's Name License No. Phone 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ x OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS cz> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Mante�///#-Depth Dia. of Well Excavation Dia. of Well Casing CJ El Domestic/Private ElGravel Pack C] Tracy Type of Casing Specifications 11Public ❑ Other ElDelta of Grout Seal Type of Grout ❑ Irrigation ---Approx..Depth ❑ Eastern Surface Seal Installed by Repair Work Done--- L7 _Type of Pump H.P. State Work Done O Well.Destruction 1< ❑ Well Diameter .,Sealing Material (top 501 Q, y Depth Filler Material (Below 50') (� TYPE OF-SEPTIC WORK: -NEIN,INSTALLATION P5 REPAIR/ADDITION ❑ .DESTRUCTION ❑ {No septic system permitted if public sewer is v available within 200 feet.) Installation will serve: Residence_ Commercial�VI'l-Other Number of living units: Number of bedr ms ~ Character of soil to a depth of 3 feet: �' Water table depth SEPTIC TANK Type/Mfg - Capacity,/o74D No. Compartments 2 PKG. TREATMENT PLT.-.❑— Method-of-Disposal, �. Distance to nearest: Well Foundation 7�, Property Line LEACHING LINE 4-Z _No.__&.Length_of,lines_ E _T.otal_fength/size FILTER BED i ❑ Distance to nearest: Well Foundation 4 — -i-'to Property Line Y ' SEEPAGE PITS _ ❑ ,Depth Size_ Number J _+ SUMPS; ❑_ 'Distance to nearest: Well Foundation Property Line `' DISPOSAL PONDS Cl' hereby certify that I have prepared this application an_d,that_the work will be done in accordance with-San_Joaquin_county_ordinances,-stateAaws, and rule`s 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." The applicants must call for all required inspections. Completes dra mg on reverse side. Signed C /leo e. � Z Date: FOR DEPARTMENT USE ONLY Application Accepted_by- � - - - — —-Date—— --Area- 412— Pit LPit or Grout Inspection by Date Final Inspection by ^�`� 'Date AZdition om ts: C �j �� -� 1 tk 466-6781 J ❑ Lodi 369-3621 LrManteca 823-7104 ❑ T cy 5-6385 Applica all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE MOUNT REMITTED CAS; RECEIVED BY DATE y� PERMIT NO.. + EH 13-24[REV.101831 7pW/-#P`-Z4 EH 1428 ' IIl��ll lJ �_r'k