84-598 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCK-ON, CA j 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. Job Address —�� F [ ��`�� City �J Lot Size � PM iOwner's Name Address Phone Contractor's e• license — Phone NamNo. TYPE OF WELL,/PUMP: NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESb DISPOSAL FLD. PROP. LINE FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ Type of Casing Specifications W ❑ Public El Other ❑ Delta Depth of Grout Seal Type of Grout_ r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done Type of Pump _ H.P. State Work Done 1 Well Destruction 1 El Type Well Diameter Sealing Material /top 501 Depth 30" Filler Material (Below 501 •� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,/% DESTRUCTION ❑ (No septic system permitted if public sewer is /R sem. - available within 200 feetJ [� Installation will serve: Residence Commercial . Other Number of living units:_� Number of bedrooms _ f Character of soil to as depth of 3 feet: ' Water table depth -� Sy SEPTICJANK ❑ Type/Mfg Capacity 1,42 G D No. Compartments PKG. TREATMENT PLT. ❑ Method of Disp sal / i Distance to nearest: Well Foundation / u --.00 Property Line ..._..,__ LEACHING LINE No. & Length of Tines ® Total length/size Q r r FILTER BED ❑ Distance to nearest: Well Foundation^!O Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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-Healfh 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."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work far which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu ca for all r rred ins ctions. Complete drawing on'-reverse side. f Signed Title: — Date: �2 / FOR DEPARTMENT USE ONLY { �J Application Accepted by L ,��3 Data "�� Area Pit or Grout inspection by Date Final Inspection by Date `s Additional Comments: a " ❑ Stk 466-6781 ❑ Lodi 369 ❑ 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 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. k INFO CASH L +EH 13-24/REV.101831 1 j -S9 I? i EH 1426 /