83-1335 - Laserfiche WebLink

Home Browse Search

JIMr APPLICATION FOR PERMIT f1 , SAN JOAQUIN LOCAL HEALTH DISTRICT (•~ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED oD (Complete in Triplicate) W 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 Cou ty 07 ance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A 1 Job Address0— / I L )j t Lel ��• �= City C9� Lot Sizes_c��e-� PM Owner's Name D { %(Nl L91A �7 Q,"J\SIN Address . ww Phone Contractor's Name act, S License No. WLG 5'S Phone ~6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial IT Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 4 ` El Irrigation --Approx. Depth El Eastern Surface Seal Installed by !" Repair Work Done ❑ Type of Pump H.P. State Work Done -9 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Jr REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial Other available within 200 feet.) Number of living units:� Number of bed ms� f't Character of soil to a depth of 3 feet: Va Water table depth SEPTIC TANK 9'Type/MfgG— �Lf?T1< 1 C Capacityala�(D No. Compartments -�-� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 2r No. & Length of lines Tot?llength/size d FILTER BED ❑ Distance to nearest: Well J I D ` Foundation ID _ property Line '7- SEEPAGE PITS Depth Lloo P Size Number �-- 1 SUMPS Distance to nearest: Well 11®! Foundation SO' 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 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 for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The appli mu all for all required in tions. Complete drawing on reverse side. S 1 � � a Signed Tit 1 Date: � i IF3 ` FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date'Z`� Additional Comments: ❑ 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 FEE EH 13-24 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT`NO. +EH 1428(REV.10/831 d C> 3�q �'3-1335