84-485 - Laserfiche WebLink

Home Browse Search

00 i APPLICATION FOR PERMIT 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 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. Job Address r . City Size p►yl Owner's Name Address Phone �-�E- �L�C ��LLLicense N Contractor's Name o. � � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 - ❑ Industrial ❑ Open Bottom ❑ Manteca ,Dia. of Well,Excavation Dia. of Well Casing -EE-Oomestic/Private•- D-Gravel-Pack—��---Q-TraC . -"-� I —e of Ca'sin' s y yp 9 - ❑ Puhlic _ _ ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation : _ W ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction Ll Well Diameter Sealing Material Itop 501 1 Depth FFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION Ll i- ESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Regidence !/Commercial,�Other - Number of living units: l Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK' " —L- -Type/Mfg' —'��'""_- Ca acit` y No. Compartments P PKG. TREATMENT PLT. ❑ t n Method of Disposal I :Distance to nearest: Well Foundation Property Line LEACHING LINE -/f 12"'N,. & Length of lines Total length/size O FILTER BED ❑, Distance to nearest: Well' Foundation Property Line SEEPAGE PITS &---Dpth LSize SUMPS Cl ,Distance to nearestii;" Well. oundation Property Line DISPOSAL PONDS ❑ r _ 1 hereby certify that I have prepared this application-analthat the work will be done in accordance with San Joaquin oc unty ordinances, state laws, and 1 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 pe formarice of the wofkxfor which this permit is issued, I shall not employ any pefson in such manner as to become subject to workman's compensation laws of California."Contiactor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work.for-whj6h this permit is issued,I shall employ persons subject to workman's compensa- laws of Califor "a." - The app t must ca for�re� d i pections.Complete drawing reverse Sig Title: ,4 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date C2 —4Z Area_ p Pit or Grout inspection by Date V 7 Qj� Final Inspection by 4, Ad Eonal Comments: - Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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# CEIV6D BY DATE PERMIT"NO. INFO CASH + EH 13-24IREV.14/831 EH 14-28 y _ -p