84-346 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED l i (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 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 / ` N� City LAA'1 Lot Size :7— ' ` -ocef M Owner's Name —14 GC B /Address 5 Phone (tl� Irl�l S Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION 0. . - PUMP . .PUMP INSTALLATIOIy SYSTEM REP ElrOTHEF� 11DISTANCE TO NEAREST: SEPTIC TANK 400 II SEWER LINES /0 DISPOSAL FLD/ 00 PROP. LINE FOUNDATION �D AGRICULTURE WELL OTHER WELL PITS/SUMPS/�� 7 INTENDED USE TYPE OF WELL PROBLEM-AREA„ICONSTRUCTION SPECIFICATIO S ❑ Industrial enBottom ❑ Manteca Dia. of Well Excavation pia, of Well Casing Domestic/Private �jp ravel Pack ❑ Tracy Type of Casing_, Specifications 1 ❑ Public .� :T ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout irrigation ---Approx. DeptEastern Surface Seal Installed by Re air Work Done ❑ Type of Purn H.P. Z4 State Work Done Well Destruction ❑ Well Diameter _� ., Sealing Material (top.50') Depth_-7-rA 30 Q Filler Material (Below 50') TYPE OF SEPTIC WORK: .NEW INSTALLATION ❑ REPAI_R/ADQUION ❑; DESTRUCTION ❑ (No septic"syystem-permitted if public-sewer is r available within 200 feet.) i Installation will serve: Residence— Commercial Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No'&'Length of lines A Total length/size FILTER BED ❑ 'Distance to nearest: well ,x Foundation Property Line s SEEPAGE PITS ❑ Depth Size Number 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 6strict. -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 f employ any person in-su'ch 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 for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins y ns. Complete drawing on reverse side. 1 .Signed X Title: Date: ^ Al FOR DEPARTMENT USE ONLY Application Accepted by Date rea 47 Q� Pit or Grout Inspection by at Final Inspection by / ate Additional Coimments: ❑ 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 95201 S FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE P`ERMIT`NO. +£H 13-24IREV.10/835 c^� �` J� EH 14.28 �S ' C7.a 1 l tilg 1 !1 7