84-1104 - Laserfiche WebLink

Home Browse Search

A�7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 pnd the Rules and Re ulations of the San Joaquin Local Health District 7 Job Address W" ,0VR&A'/-1f'. � /LJ) City % _ 'Lot Size �} � �� PM Owner's NameG11iLr},Jddk&__ Address __ 4& -- - Phohe ' A"3% Contractor's Name r-- AV-S License No. S_Y'--' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ P3 STSUCTIQN ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ❑ a DISTANCE T,4 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type.0f.9rovt:. ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ``� H.P. State Work Dong Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is / *\� available within 200 feet.) Installation will serve: Residence V Commercial_ Other Number of living units:-/— Number of bedrooms -1 �. Character of soil to a depth' of 3 feet- �x G►Cf.f'� _ Water table depth SEPTIC TANK ltd Type/Mfg � �2/.TH Capacity /.e No. Compartments %�- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 49 Foundation __tl Property Line '�0'19 LEACHING LINE No. & Length of lines 4 Total length/size X :! 7g9 FILTER BED ❑ Distance to nearest: Well ZZ49 Foundation lg Property Line Z i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑' =' 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joapuin 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: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any penton 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 applicant must call for all required inspections. Complete drawing on reverse slide. Signed XTitle: Dates ` FOR DEPARTMENT USE ONLY ! Application Accepted by Date "v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 486-6781 ❑ Lodi 3683821 El Manteca 823-7104 ❑ Tracy 83545385 Applicant- Return all copies to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F'FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT"Np. +EH 13.24 MEV.101631 EH 11.26 1 ' t