84-934 - Laserfiche WebLink

Home Browse Search

` L '• ` � APPLICATION FOR PERMIT 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -7,-?`J_ oo /c'1/5/V,00VZ' City S T/C Lot Size Z X'1 Q 0 PM Owner's Name 61r,4L aP CZ V 491-J'f 4 Address Phone s ,._. w Contractor's Name ,9�f�►`./c'f.�f� 1-X0&-S. License No. 2•��9 s V1 Phone ? � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ 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 (top 501 Depth Filler Material (Below,E,) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence 'v Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C f 19Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - — Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Z Property Line S" SEEPAGE PITS Depth �. Size Number SUMPS ❑ Distance to nearest: Well, B_ Foundation JJ- 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. 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: LSA` Date: . L�%%� — / FOR DEP RTMENT USE ONLY Application Accepted by Date ?��I O� Pit or Grout Inspection by Date Final Inspection b Date Additional Commen — ❑ Stk 466-6781 ❑ 66di 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. +EH 13-24(REV.10183) EH 14-28