84-1184 - Laserfiche WebLink

Home Browse Search

.0 W APPLICATION FOR PERMIT �V_5��4 - fZluv,ti6ltu+_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA fGr�r` Telephone (209) 466-6781 ! !°S', ' — No VdD-,,,>/E PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 11-(c.a k �i`I`it� y�1�✓1-Yw (Complete in Triplicate "Ay, 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. f� ` Job Address � QiA City C A) Lot Size MAIM PM ' Owner's Name Address Phone9-// Contractor's Name !Pc) -) �' a x- icense-No.-. k. - Phone - TYPE OF WELL/PUMP: NEW WELL 4T WELL,REPLACEMENT-171, DESTRUCTION PUMP INSTALLATION ❑ SYSTEM/R�EPAIR ❑ r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "ao�O DISPOSAL'FLD.0?00 PROP. LINE FOUNDATION JJCIYIJF-AGRICULTURE WELLkICA)C- OTHER WELL-2V(7,1V PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-- CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion !Dia. of Well Casing 1 Domestic/Private Gravel Pack ED Tracy Type of Casing Specifications IC D Public ❑ Other ❑ Delta Depth of Grout SealType of Grout t?3 r ❑ irrigation —__Approx. pe0.t, Eastern ,Surface Seal Installed by Jl Repair Work Done ❑ Type of Pump H.P. �t State Work Done G Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is .n available-within-200 feet.) mr- Installation will serve: Residence--�--.Commercial_ Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: - ' r- Water table depth SEPTIC TANK ❑' "Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. L3 Method of Disposal f' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. i 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 applican m st' t call for all required ins ctions. Complete drawing.on reverse side. 14 Signed Title: /TDate: w FOR DEPARTMENT USE ONLY Application Accepted by "Y Date 1- b Area I Pit or Grout Inspection b ✓ —Final f y Date Final Inspection by Date �Z- Additional Comments: ❑ Stk 466-6781 ID Lodi 369-3621 ❑ Manteca 823-7104 C] Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:0. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K# INF RECEIVED BY DATE PERMIT"'fJO. (� + EH 13-24 4REV. 14!631 SX (� 1�.�{f♦1��+t� EH 14-25 C�