84-349 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT`" SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l Job Address 1Ci �+� � "Q 7 Q tY I�Lot Size pM i tt Owner's Name f� �'��1��1 Address Phone Contractor's Name � J� ��6.11 �ftLA—License No. y�� "� 9� Phone TYPE OF WELL/PUMP: NEW WELL_❑.;WELL_REPLACEMENTl.L7-;7--: -_EESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑",, +,BOTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE 71'-.FOUNDATION t".-."- �i�RE WEL . f - THER-WELL_ PROP. .MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ' { ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation k Dia. of Well Casing _ #[ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Public Specifications ❑ Other - LJ Delta Depth of Groui Seal ` Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by d - ._Repair Work Done ❑ Type of Pump H.P. State Work Done Y Well Destruction ❑ Well Diameter Sealing Material (top 50') `- { Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION- ESTRUCTION ❑ (No septic system permitted if public sewer is - l available within 200 feet.) P�r� Installation will serve: Residence_ Commercial_ Other s' V 1 Number of living units:_-�--Number of bedrooms _7---- � - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf r+ Mfg Capacity No.-Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to nearest: fn Property Line -------------- LEACHING LINE Er--No. &-Length of lines Total length/size FILTER BED- ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS +:i�epth S Size Number ' SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS DI Property Line 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'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." f Th675pplicpnt mustch for II req r I in cti Complete"drawing o evsrse side Title ii Date 4 FOR DEPARTMENT USE ONLY Application Accepted by Date J ' ( Area Pit—or Grout Inspectpon by"I _�jyr....� 9 '-''-'(�„ Date'-� .._-d?� -=-Fir�4-}nspeetion=by sc Date�3 Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3e21 ❑ 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' INFO y _ -':CASH13W9 DATE PERMIT"NO. +EH 13-24(REV,101831 1 _ ��J aq4_�2r J �,/ .—�`/� Ek 14 26 S ti 7` 0 `-It' L{f�;li