84-33 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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.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.�JL Job Address o /F✓� b/ lIxWJ 1V ._ City 1_ 1A1'1ft !bf Lot Size �.Fyo n, PM Ownis Name r �_5 0 .V-64N I v F/I r� I Address �� _ Phone I _4 - ' .. 4Contractar's Name 4 �l`t�1C�iOIL License No. Phone .� + TYPE OF WELL/PUMP: y..I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑„ SYSTEM REPAIR 171 OTHER ❑ ' .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL f4't PITS/SUMPS-= INTENDED USE TYPE OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS T I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private f ❑ Gravel Pack ❑ Tracy -M- Type of Casing Specifications ❑ Publics- , ! ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Ifrigationr\ _ "' —Approx. Depth ❑ Eastern 4 �-5urfaceieal Installed by Repair Work Done' 10Type_of_P,u pm +'`- H.P. State Work Done Well Destruction C]: Well•Dia a ei _ Sealing Material {top 50'1 ;,%.N j" Depth /1 '+ I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR•/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is '-J .� available within 200 feet.) 1S` Installation will serve: Residence Commercial_ Other _ 1 Number of living units: Number of.D doms D Character of soil to a depth of 3 feet: -/ -� rih.,` - "`' Water table depth a SEPTIC TANK X Type/Mfg J1�-Z;41� 711C1'ek Capacity P No. Compartments Z r.�.s PKG. TREATMENT PLT.',❑ � •� '� � � �~ � Methad�of�Disposal j l Distance to nearest: Weli� s Foundation Property Line LEACHING LINE No. & Length of lines 4Z Total length/size 80 FILTER BED Distance to nearest: Well _'{Vp-p"foundation _?b ^Z4 Property Line___.. rr SEEPAG' PITS �.3-..a Depth Size A Number (SUMPSi� ON ` j❑ Distance to nearest: Well 100 Foundation 00 Property Line �� DISPOSAL-PDS�l "her eby 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." Contractors 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 CIffor The applicant m f for all required inspe tions. Comple#e drawing on reverse side.._ Signed - � Title:__� rwIUC�JI J Date: I FOR DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by Date—1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ 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 DUEAMOUNTAMOUNT REMITTED CAST{ RECEIVED BY DATE {PERMIT`NO. +EH 13-24(REV. �o�s3� �� ' .� ._.... s I--1(- 8q �-33_ l r EH 1426 "I