84-961 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) I� 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. l Job Address -^� City !! Lot Size PM G Owner's Name Address Phone t sy_ Contractor's Name &4aR&"3 kV,422;E& License No. Phone TYPE OF WELL/PUMP.:--______,NEW.WELL.❑_WELL_REPLACEMENTS E] DEST•RUCTION.,❑— , PUMP INSTALLATION IAIIFAi.SYSTEM REPAIR JI@y 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 X70pen Bottom ❑ Manteca Dia. of Well Excavation f17 Dia. of Well Casing 112 ". -Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications E3 Public 130 ther ❑ Delta Depth of Grout Seal 0%Affle ofGrr ,*Irrigation _3LVj2!Approx, Depth ❑ Eastern Surface Seal Installed by I7f Repair Work Done ❑ Type of Pump SUA- H.P. -`_1� State Work Done Well Destruction 3 ❑ Well Diameter Sealing Material {top 501 ^� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is x available within 200 feet.) s Installation will seive: Residence_ Commercialf' Other_ � VV Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ]L" Distance to nearest:- Well Foundation Property Line l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well i ` _fFoundation Property Line SEEPAGE PITS ❑ Depth Size }" i Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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•6censed 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 applicant must call for 11 required inspections. Complete drawing on�reverse �side. err Signed X Title: _Z/ Date: . i FOR DEPARTMENT USE ONLY � J /7/- a Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ate` v Additional Comments: 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 831-6385 - A! pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1428 IREV.10/831