84-310 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 I C� Telephone (209) 466-6781 r/ DATE ISSUED c3"l2?3 /Y 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 v Subdivision Name. Lr Pl -c w Owner's Name Address $ a�-+ �� ad�J�✓ctrc'� Phone Contractor's Name Cr?L/ar /)n /&Uz License No. `/ 3-( Phone fp 3.,)- 7/9t� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALL TION (❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /4Btr f DISPOSAL FLD. (OP/ PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /� Q) ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation r Domestic/PrivateGravel Pack ❑Tracy Dia. of Well Casing (� Public ❑ Other ❑ Delta Type of Casing J Ah/,`- / F, irrigation Approx. ❑ Eastern Depth Specifications 1 r ��9�f� ❑ Cathodic Protection Depth of Grout Seal ❑GeophysicalType of Grout /�f Pl Toil/ 7� ❑Other Surface Seal Installed by 04"N Fs/ Repair Work Done [-J Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamete Sealing Material (top 50') Depth �— Filler Material (Below 50') TYPE OF SEPTIC WORK: NEMC_INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permit-ted i-f-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 ( n PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth SizeNumber 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. 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." 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 applicant�t cal for 1 required inspections. Complete drawl on reverse side. Signed X 'C/Ln f� �vif.�✓vL�y/ �� Title: / Date: , l-..Z__ / DEPARTMENT USE ONLY Application Accepted by 40,M Area ❑ Stk 4fi6-6781 Additional Comments: ❑ di 369-3621 Pit or Grout Inspection by 0.. i Date 3� �� Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE NO. INFO 4 S 313-? J;PE7RMIT - 0 EH 13-24 REV. 10/82 10/82 500 14-26