84-288 - Laserfiche WebLink

Home Browse Search

vim APPLICATION FOR PERMIT SAN JOAQUIN" LOCAL HEALTH DISTRICT MAR 1 1984 1601 E. HAZEL—i ON AVE", STOCKTON, CA Telephone (209) 466-6781 wo HEALHE ATH DI RIOTLOCAPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y^ (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 Health District. ,e Job Address �011s- �A ��l9[s City ze PM Owner's Name ss 0i3 . 40412U[I�hn. Contractor's NameA License No. �[D 37,3 Phone��`� � TYPE OF WELL/PUMP: NEW WFFL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER-E] - — 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'SPECIFICATI.ONS _ ❑ Industrial ❑ Open Bottom ❑"Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications", ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ❑ Irrigation _.__"Approx. Depth Eastern Surface Seal Installed by Repair Work Done W Type of Pump s4 H.P. State Work Done �y Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is y available within 200 feet.► Installation will serve: Residence_ Commercial_ Other r 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 C` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size _ Number _ y 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. r.,.-n —.. Home owner or lice '4 sinature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person" such manngss to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the follo ing: "1:ail>l�.,ired t" the performanc of the wor which th' permit is issued, I shall employ persons subject to workman's compensa- tion laws of C Iforma." , X The applican must in c' awing o averse side. rCIASigned i mate: FOR DEPARTMENT USE ONLY Application Accepted by 4" ` Date " Area 4!�POC7-1 Pit or Grout Inspection by Date Final Inspection by Date -3 a 7 Additional Comments: ' ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13.24 1REV"10!63) EH 1428