84-164 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Number of living units. um Character of soil to a depth of 3 feet: i Type/Mfg, i YY SEPTIC TANK El PKG. TREATMENT PLT. ❑ Distance to to. nearest: Well No. 8� Lerigth of lines Z T2tallength? size LEACHING LINE X FILTER BED ❑ Distance to nearest: Well Sa Foundation _/ G Property Line` { SEEPAGE PITS ❑ Depth I Size Water table depth Capacity No. Compartments _ Method of -Disposal . Foundation Property Line SUMPS ❑ Distance'to nearest: Well Number Foundation Property Line DISPOSAL PONDS ❑ F 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. that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify employ any person in such manner as to become subject to workman's compensation laws of CaVornia." Contractor's hiring osubject u wookmantls comnature tify certifies the following: "I certhat in the performance of the work for which this permit is issued, I shall employ.pe rsons pensa- tion laws of California." The applicant must cal for all req i e ctions. Complete drawing on reverse side. _ Title: Date: Signed _ ..T.._ - T FOR EPARTMENT�USENLY I Date �w Area Application Accepted by f Date Final inspection by Date Pit or Grout Inspection by Additional Comments: L3Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83x6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK # RECEIVED BY DATE PERMIT `ND. INFO AMOUNT DUE AMOUNT REMITTED CASH �`�" ,-- �► H��' �—_ �` �! b/mss �'� 1 b'y + EH 13-24 {REV. 107531 _ _ - EH 14-26—. 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 .loagwn Local Health District for a permit to construct and/or install the work herein described. This application is for or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin made incompliance with San Joaquin County Ordinance No. 549 sewage Local Health District. -7 , �� I — ��`� Lot Size �T� PM / Q l City Job Address 9 -3 7a /J /� ` / STS 7 s " r fie- 1 Phone Owner's Name A��x �.4 Address . - -- . `5 Phone SkContractor's Name i I' License No. WELL REPLACEMENT ❑ DESTRUCTION 13 TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR 11 OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLR. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION, INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ industrial E3 Open Bottom ❑ Manteca Dia. of Well Excavation { Casing Specifications ❑ Domestic/ Private of Tracy { 7 e of Grout .1010 El Gravel Pack ❑ Depth of Grout Seal Type Public C1Type ❑ Other Delta El Eastern Surface Seal Installed by r w ❑ irrigation �4ppro2Depth f State Work Done H P Repair Work Done El Type of Pump a Sealing Material (top 50') Destruction Well [I Well Diameter] Depth Filler Material IBelo+iv 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT101�DESTRUCTION Elavail'abpe�within 200 feet�ijed if public sewer is Installation will serve: Residence — Commercial _ Other c^ 1 N ber of bedrooms Number of living units. um Character of soil to a depth of 3 feet: i Type/Mfg, i YY SEPTIC TANK El PKG. TREATMENT PLT. ❑ Distance to to. nearest: Well No. 8� Lerigth of lines Z T2tallength? size LEACHING LINE X FILTER BED ❑ Distance to nearest: Well Sa Foundation _/ G Property Line` { SEEPAGE PITS ❑ Depth I Size Water table depth Capacity No. Compartments _ Method of -Disposal . Foundation Property Line SUMPS ❑ Distance'to nearest: Well Number Foundation Property Line DISPOSAL PONDS ❑ F 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. that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify employ any person in such manner as to become subject to workman's compensation laws of CaVornia." Contractor's hiring osubject u wookmantls comnature tify certifies the following: "I certhat in the performance of the work for which this permit is issued, I shall employ.pe rsons pensa- tion laws of California." The applicant must cal for all req i e ctions. Complete drawing on reverse side. _ Title: Date: Signed _ ..T.._ - T FOR EPARTMENT�USENLY I Date �w Area Application Accepted by f Date Final inspection by Date Pit or Grout Inspection by Additional Comments: L3Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83x6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK # RECEIVED BY DATE PERMIT `ND. INFO AMOUNT DUE AMOUNT REMITTED CASH �`�" ,-- �► H��' �—_ �` �! b/mss �'� 1 b'y + EH 13-24 {REV. 107531 _ _ - EH 14-26—.