84-1259 - Laserfiche WebLink

Home Browse Search

APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 `�r 4 L L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I! -` i'r4 (Complete in Triplicate) 197. () Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heroin 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. { w Job Address ? �' 6��llf?.Q /?Q :. City_�1 r/� - Lot Size �� PM . Owner's Name�/C�/C�_� / / ��/,�i�l� Address W Phone Q-6_ Contractor's Name /r'/��/l`' 11 s �+�CS _ License No. cT4l s3�.� hone +!(` d 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 s , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationes pia. of Well Casing_ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing's r Specifications ❑ Public l ❑ Other ❑ Delta Deptl1 f G ut S el` � t.Typa of G`Grout gatlOn ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 'State Work Done t Well Destruction ❑ Well Diameter Sealing Material [top 501 , DepthFiller Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION ❑ DESTRUCTION ❑ '(No septic system permitted if public sewer is availebje•wlthin 200 feet.l Installation will serve: Residence Other--_"✓ ; Number of living units:_� Number of bedrooms ,. Character of Wl'to a depth-of 3 feet: XZ2i ,9'X' 4f1'!r'?/X "_.5 " Water table depth ae SEPTIC-TANK ❑ Type/Mfg ,Ia/�" eZ&CZ H Capacity At 40 No. Compartments L PKG. TREATMENT PLT:❑ / r Method of Disposal '4 -4t eL0 Distance to nearest: WeII/A?� --_�Foundation lD _ Property Line LEACHING LINE P�No. & Length of lines _ Total length/size FILTER BED ❑ distance to.nearest x WeIIC �� Foundation�G Property Line 77�\ i 1,0f�.. . . �rI SEEPAGE PITS` C3 Depth Zi Size 3. Number Z SUMPS '' ~-��.'Uistaa to nearest: Well ALL" Foundation -96 Property Line DISPOSAL.PONDS 23 I hereby.certlfy 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 r employ any person in such manner as to become subject to workr.inn's compensation laws of California."Contractor's hiring or sub-contracting signature j .certifies the'following:"I certify that in the performance of the work for which this permit Is Issued,I shall employ pereons subject to workman's compensa- tion laws of California." i y ,rThe applicant MW'call for all required Inspections. Complete drawing on reverse side. Signed X Title: t Date: 1 MENT USE ONLY Application Accepted by Date — Area Pit or Grout Inspection by Da to 222?7 Final Inspection by C.r Date Additional Comments: - ❑ Stk 4664781 ❑ Lodi 389-3821 ❑ Manteca/823-71t14 frac"" ' Applicant- Return all copies to: Environmental Health Pormk/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO 11 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EN W24(nEv.10183)26 : 0 1'2b $L1-1ZS