84-809 - Laserfiche WebLink

Home Browse Search

" APPLICATION FOR PERMIT T 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin � Local Health District.. Jab Address "J7� I'1 u, _ City C 1' /� Lot Size �1 PM r Owner's Name T 1 Address __Ct 8 V6 [� -- t Phone 7 3'] Contractor's Name License No. Phone n{ TYPE OF WELL/PUMP: NEW WELL ❑ .,.,.,:_„WELL REPLACEMENT ❑ DESTRUCTION q ' PUMP INSTALLATION'-❑ $ 5 SYSTEM"REPAIR•❑- _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK "SEWER--LINES `' I DISP05AL FLD. '^ PROP. LINE FOUNDATION AGRICULTURE WELL—_!:— OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 c ' ,. El Industrial �' . ❑ Open Bottom ❑ Manteca -Dia. of Wel! Excavation Dia. of Well Casing , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } ❑ Public f ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation — —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') l Depth Filler Material (Below 501 ^i l pTYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � L 9 available within 200 feet.) j Installation will serve: r Residence L Commercial Othei +� C-`! `�� r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Lopprn^ V; Water table depth SEPTIC TANK Type/Mfg Qs*aEf� `Capacity 12 Water 0 Compartments 3 PKG. TREATMENT PLT. ❑ fti Method of Disposal i 1 Distance to nearest: Well too Foundation ICJ Property Line LEACHING LINE No. & Length of linesTotal IengthLsize Q FILTER BED ❑ Distance to nearest: Well 16 b r Foundation Property Line k SEEPAGE PITSct - &—ftpthSize —Number a SUMPS El Distance to nearest: Well ,` Foundation i. �-6�— Property Line_ ' DISPOSAL PONDS ❑ r 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 agents signature certifies the following:"T'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 applicant m call for all required ins tions. Complete drawing on reverse side. g r - Si ned - Title: y; Date:'' FOR DEPARTMENT USE ONLY Application Accepted by ! Date �-''t� Area I Pit Inspection or Grout Ins — k . pe b Y date Final Inspection by��' _ Date I Additional Comments: ,�� ' ❑ Stk 466-6781- ❑ Lodi 369-3621 ❑ Manteca 823-7104 f" ❑ Tracy 835-6385 �— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. B8x 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCRECEIVED BY INFO .-CK-SH DATE PERMIT`NO. + EH 13-241REV.141831 °�� . „x.[ + �'� �--� 3 ^$ f EH 1426