84-1268 - Laserfiche WebLink

Home Browse Search

i APPLICATION,FOR PERMIT SAN JOAOUIN'LOCAL FI ALTH DISTRICT '` I 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone (209) 466-6781 M PERMIT EXPIRES 1 YEAR.FROM�DATE ISSUED , / .{Complete in Triplicate) r:`I 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 I, 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..,3; Joh Address � C". Lot Size a 1 rGr 1— -8SS —. 2►i/ e' ALI- ? -� wsr ower .•a s - - _ Owner's Name r Address `^* Phone t Phone Contractor's Name _ _ _ icense No �� j TYPE OF WELL/PUMP:- _ NEW WELL F-1WELLREPLACEMENT LD DESTRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 CONg TRUCTIQN-SPECIFICATIOfJS ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 11Tracy Type of Casing Specifications i [I Public El Other [I Delta Depth of Grout Seal Type of Grout ❑ Irrigation __-Approx. Depth ❑ Eastern—Surface-Seal-Installed-bye 0 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well D!ameter Sealing Material._Stop.50'W:! — N f Depth ( Filler Material (Below-50'1 — lQ�1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION &.- DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) .,- Installation will serve: nce Commercial• Rldether T0'Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:'— Water table depth � �� — SEPTIC TANK C1 Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to ne� �dNaion �_ Property Line LEACHING LINE L NO. & Length of lines .r ► l Total length/size f � V FILTER BED ❑ Distancetonearest: Well -FoundatioriA 1 !- Property Line SEEPAGE PITS Ei;.4Depth � �Y-Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 i rules and regulations of the San Joaquin Local Health District. 11_} �.; �{ Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work 1. =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."shllContractors hiring or sub contracting signature ce the following:"I rtify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la California." }} The applicantN call fo all r ured i coon . Co ate drawin oRverse std J. ' Si Tiler , _ Date. 9 FORD PARTMENT USE ONLY C/ V Application Accepted bye r i Date Z� ! Area Date Pit or Grout Inspection by Date - Final Inspection by - Additional Comments: i •❑ Stk 466-6751 ❑ Lodi 369.3621 ❑ Manteca 8Z3-7104 ❑.Tracy 83 -1=8 Ivor-f prl Applicant- Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE' AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE f ERMIY'N0. ' INFO + EH 13-24(REV,10fe31 'b EH 1428