84-506 - Laserfiche WebLink

Home Browse Search

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. TMs 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 �PMJLocal Health District. f� Z�spw�V FesET �I �,,4 � 0?�O�-0�. � Lot Size ob Address n Owner's Name 1 Address © !S Phone Contractor's Name License No. 32?Z1 Phone -�ZIb TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 7EPAIR ❑ OTHER ❑ // i DISTANCE TO NEAREST: SEPTIC TANK O ! SEWER LINES �SC� DISPOSAL FLD! // PROP. LINE/�I FOUNDATION " AGRICULTURE WELL ""` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f,Z Dia. of Well Casing O Domestic/Private Gravel Pack ❑ Tracy Type of Casing ,1 Specifications C 1 vI Public ❑ Other Delta Depth of Grout Seal /St C1.rtTT_ Type of Grout .vI La ElIrrigation 2--S-"Approx. Depth ❑ Eastern Surface Seal Installed by A .'L Repair Work Done ❑ Type of Pump H.P. State Work Done m Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence— Commercial_ Other 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 �i✓ Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Tota! length/siz - FILTER BED ❑ .Distance to nearest: Well Foundation Property Line u SEEPAGE PITS ❑ 'Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 4DISPOSAL PONDS F-1 I 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 0� 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 supject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in-;the perforrilance 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 or a sre wired inspections. Complete drawing on reverse side. Signed ` Title: 1 Lex Date: FOR D ARTMENT USE ONLY �- Application Accepted by*, E-362 /j/j Date /! Area Pit or Grout Inspection ' l Date 8 Final Inspection b Date Additional Comments: _ ❑ Stk 466-67811 ❑ Manteca 823 7104 ❑ Tracy $3�r6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201- INFO �yFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. + EH 13-24(REV.161631 `► 00 /g� �`1 S�� EH 14-26