84-297 - Laserfiche WebLink

Home Browse Search

m c APPLICATION_FOR'PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT �`l_7 LACI 1601 E. HAZELTON.AVE., STOCKTON, CA PERMIT NO. `l Telephone-(209) 466-6781 rT !QDATE ISSUED PERMIT EXPIRES•1'YEAR FROM DATE ISSUED -• (Complete in Triplicate) Application is he bymadeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This pplicatian 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 5ari'Joa iri Local Hdalth District, Jab Address Subdivision Name Owner's Name ° ` Address `Phone Contractor's Name License No. Phone 9 / l TYPE OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ �+ PUMP INSTALLATION T SYSTEM REPAIR OTHER , DISTANCE TO NEAREST: SEPTIC TANK _ T SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL P1TS%BLIMPS 9 �} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom Manteca - .Dia.,of Well,Excava£ionv_ ❑ Domestic/Private ❑Gravel Pack [] Tracy Dia, of Well Casing �-Public Other [] Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth .pepth of Grout Seal ❑Geophysical ".Type of Grout ❑Other n Surface Seal Installed by Repair Work Done ❑ Type of Pump er H.P, �/�, / _ State, Work Done/ 0 erJ7o-de 7uz. Well Destruction Well Diameter .Sealing Material (top 50') Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION '❑ (Neseptic 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.;-Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal I� SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ r,-__ LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED [] Distance to nearest: Well Foundation Property Line SEEPAGE PITS [) Depth Size Number t SUMPS U 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 San Joaquin Local Health District. t 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." ti 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 applican must call for all required inspections. Complete drawing on reverse side. a Signed X a Title: - Date:a_ D'O FOR-DEP TMENT-US :ONLY Appi ication Accepted b}(/✓ O Area d Stk 466-6781 Additional Comments: Lodi . 369-3621 t Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by r Date � Tracy 835-6385 Applicant - Return all copies to: nVinmenta Health Permit/Services 1601 E, Hazelton A P.'0: Box 2009, St k., CA 95201 ro FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED'BY DATE PERMIT NO. INFO00 5 4 EH 13-24 REV. 10/82 10/82 500 # 14-26