84-118 - Laserfiche WebLink

Home Browse Search

3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 { DATE ISSUED 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 }iealth District. Job Address r'�Y/• LJ AA tow/ Subdivision Name Owner's Name ddress -� O C Phone Contractor's Name 'cense No. 1,72 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ CrX! PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ) DISTANCE TO NEAREST: SEPTIC TANK —/00 f" _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._fQQ`yt INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private DdGravel Pack ❑Tracy Dia. of Well Casing j6 a ❑ Public ❑Ot,er ❑ Delta Type of Casing V C ❑ Irrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal � ❑Geophysical Type of Grout LF Other �+ Surface Seal Installed by L RSA A, 6 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION E LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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-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§ compensation laws of California." Contractor's hi g or sub-contract in signature certifies the following: "I certify that in the performance of the work for which this permit is . sued, I s to persons subject to workman's compensation laws of California." The app lica ust call f all requ ed inspecti ks. Complete dr wi g on reverse side. p Signed Title: C101V T e T4 Date: '-d OR RTMENT USE ONLY Application Accepted/by Area E] Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by E Date C T Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE OUNT DUE AMOUNT REMITTED RECEIVED BY GATE B PERMIT NO. �� INFO f EH 13-24 REV. 10/82 14-26