84-868 - Laserfiche WebLink

Home Browse Search

VAPPLICATION FOR PERM;T SCANNED SAN JOAQbiN LOCAL HEALTH DISTRICT t7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Subdivision Name Owner's Name Address Phone Contractor's NameLicense No. `3 ZAZZ/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER D fes^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE \1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Lj Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑Other Delta Type JP Irrigation pec of Casing Li 9 Approx. ❑Eastern "Cr Depth Specifications ❑ Cathodic Protection p Depth of Grout Seal ❑Geophysical Other Type of Grout Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence ✓ Commercial Other Number of living units: Number of bedrooms Lot size e4/✓/.3a Y Character of soil �t,o,/a depth of 3 feet: Water table depth u SEPTIC TANK Type/Mfg 'a. Capacity No. Compartments -.P-- PKG. ZPKG. TREATMENT PLT. E] Type/MfgCapacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well T Foundation /O! Property Line DESTRUCTION ❑ //++ 'L LEACHING LINE No. & Length of lines Total length/size /aQvLf—fZ _ FILTER BED Distance to nearest: Well Foundation J Coi f Property Line SEEPAGE PITS Depth 5r1 Size /#2 n Number 3 SUMPS ❑ Distance to nearest: Well //ice/4Foundation lGr.f Property Line DISPOSAL PONDS 'Y"— EDI 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 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 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 compensation laws of California." The applicant st call for all qui red inspections. Complete drawing on reverse side. Signed XTitle: Date: �f FOR DEPARTMENT USE,ONLY Application Accepted by �Q Area E] Stk 466-6781 Additional Comments: Y Lodi 369-3621 (9or Grout Inspection byDate l2-K`� Manteca 823-7104 Final Inspection by Date v ❑ Tracy 835-6385 Applicant - Return all copie to: Environmental He6lth Permit/Services 1601 E. Hazelton A0, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED R�ECyE�IVED BY DATES PERMIT N0. INFO I 7 C �l ,S W �--/// ,3/ F—n-k- EH 13-24 REV. 10/82 v 10/82 500 14-26