84-1544 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ? l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 we /pump and the Rules and Re ulations of the San Joaquin L/ 1 Health District. V Irrigation Approx. Job Addressyks Subdivision Name Owner's Name ,4 Address (/ +� Phone • 10 ..-7 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION F - SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 1 PROP..LINE FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA Industrial U Open Bottom Manteca U Domestic/Private F-1 Gravel Pack Tracy Public F-1 Other Delta V Irrigation Approx. E] Eastern FICathodic Protection Depth 0 Geophysical LJ Other Repair Work Done EJ Type of Pump H.P. Well Destruction U Well Diameter , 2 / / Sealing Material Depth Z 00 0' Filler Material CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation _ Dia. of Well Casing Type of Casing Specifications Depth of Grout Seal Type of Grout Surface Seal Installed by State Work Done (top 50') ( Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. [] Type/Mfg SEWAGE SYSTEM ci Distance to nearest: Well DESTRUCTION Other Lot size _ Capacity _ Capacity Foundation _ Water table depth _ No. Compartments _ Method of Disposal Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED F-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS CJ Depth Size Number SUMPS Ll 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 SanJoaquinLocal 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 workmans 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 ' issued, I shall employ persons subject to workman's compensation laws of California." The appli ant must call for al equired inspe tions. Complete drawing on reverse s' e. / (/ Signed X Title:` Date: OR DEP 0 ❑ A ication Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date - Tracy 835-6385 Applicant - Return all copies to: Environmental alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 149 _ do- i -�/ g4 EH 13-24 REV. 10/82 ` 10/82 500 14-26 `%7 o�