84-1407 - Laserfiche WebLink

Home Browse Search

0 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL _HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 _ AMOUNT DUE . , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CASH RECEIVED BY DATE (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is made incompliance 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. Ac Lot Size PM Job Address 90Phone - 31 Owner's Name C)� ddress Contractors Name �' + License No.�' © Sn . Phone 12 -�- TYPE OF WELL/PUMP: 'ANEW WELL! ❑ WELL REPLACEMENT ❑, _;�' DESTRUCTION 116 F OTHER ❑ •." PUMP INSTAE_LATION❑ SYSTEM REPAIR_C7 _ DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES' i DISPOSAL FLD •- PROP. LINE 4 FOUNDATION AGRICULTURE WELL ZL OTHER WELL PITS/SUMPS INTENDED -USE rte. TYPE OF V�E_LC5 PROBLEM AREA CONSTRUCTION SPECIFICATIONSY ,Q-Industrial—EI-Open Bottom—_. L7Manteca ....^,r Dia. of -Well Excavation ` " g g Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy fType.of-Casing Specifications ❑ Public 'O Othery. 71L ❑'Df.elta` *3111.Depth of Group Seal Type of Grout ❑ Irrigation �ipprox. Depth ❑ Easterm Surface Seal Installed by �Y Repair Work Done [I Type of Pump 143p• State Work Done ! • WeII Destruction' v "'❑ sWell Diamefe r Sesling Material (top 50'1 O lit, Filer an I (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION;.❑4KFIEPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ++w,ro..ry' ! ; available within 200 feet.) ';_Installation will serve: Residence _ Commercial Other'—/ - =, `Number of living units Number of bedrooms t de th Character of soil to a depth of 3 feet: t`t+ `�"' � � Water table p ''SEPTIC TANK ❑, `Type/Mfg t- 11 Capacity =1 V No. Compartments PKG. TREATMENT PLT 11C `, _ Method of Dispose! 3 0oundation wProperty Line *-,fta. Distance to nearest: Well LEACHING LINE No."& Length of lines y Total.-length/size well °~ Foundati6 Property Line S� FILTER BED [01 Distance to n6arest: SEEPAGE PITS L-wDeptt�a � 2_� o Size _a 3 '� 1 - - Number SUMPS ❑ Distance to nearest ��, Well �'��Foundation �.,._— Property Line®� rZ� t �fl '� (05, i DISPOSAL PONDS'"�._.:.❑'"rte+" �lZb�' `" 'rt hereby certify thafl 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'e'-Siih Joaquin`L'ocal,HealtW, District. If; i Home owner, orlicensed ageyCe signature certifies the following: "I certify"that in the performance of the work for which this permit is issued, I shall not employ any peisor in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature is issued, I subject to workman's compensa- certifleCthe following: "I cIrtify that in the performance of the work for'whichdthis permit shall employ persons ` tion`'daws of California." j - i �r-ajgc The a .must call tpr all required i spections. Complete drawing,i reverse sideg �. Signed Title: Date: �RDEPARTMENT USE ONLY r Date / Area r Application Accepted by �T Pit or Grout Inspection by D e � Final Inspection by I ` "" Date Additional Comments: ❑ Stk 466-6781 ❑ 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 952{11 + EH 13-24 (REV. 10/83 EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO.