84-1148 - Laserfiche WebLink

Home Browse Search

t,. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. � 7J c) `� + ft� S City Lot Size PM Job Address �f Owner's Name Address ,a �h Phoneb' 1 S7 Phone 2/— 7/ Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ElDESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ DISTANCE TO NEAREST: SEPTIC TANK (3 2,— SEWER LINES i' DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL — OTHER WELL - PITS/SUMPS .L 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � jgo ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 1Z Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S�w�— Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal SQ Type of Grout \nA I \ ElIrrigation _---�4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done v Well Destruction ❑ Well Diamete Seating Material (top 50') W Depth Filler Material (Belo ) O TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 4,hear'Ost: ell Foundation Property Line 'Z LEACHING LINE ❑ Noy'&a,Length of lines Total,lenyth/size 6 FILTER BED ❑ Distance to nearest: V1ell =Foundation Property Line V SEEPAGE PITS ❑ Depth Size Number r� SUMPS 11Distance to neares Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 wdrkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of thg work for which this permit is issued,,4 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus cal or all requir inspectio Complete drawing on reverse side Signed Title: L✓f��-, �° Date: 741 FOR DEPARTMENT USE ONLY Application Accepted by Date r Areas � � .. G Pit or Grou Ins�sction by �-P Date Q��aa�'final Inspection Date � 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.10/83) EH 14-28