84-1052 - Laserfiche WebLink

Home Browse Search

II �< 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 'I (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. fi Job Address City /Lot Size PM Owner's Name /l:.C�(d�J/,5 Address `� f�R(� ` UV / sem'"^ I� =6 ®done Contractor's Name � (�� License No. C/�tr l/ A4 2 / c7f TYPE OF WELL/PUMP: Phone �' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPS INSTALLATION A!r— SYSTEM REPAIR ❑.: DISTANCE TO NEAREST: SEPTIC TANK OTHER C3l SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t�mestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing IJ Public Other Type of Casing Specifications ElDelta Depth of Grout Seal ❑ Irrigation --Approx. Depth ❑ Eastern Type of Grout Surface Seal Installed by ''y Repair Work Done Type of Pump _0l�� H.P. State Work Done of w Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth ,i Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 Installation will serve: Residence_ Commercial available within 200 feet.} ,, Other Number of living units: Number of bedrooms Character of soil to a depth of 3'feet: a SEPTIC TANKWater table depth ❑ Type/Mfg Capacity— n PKG. TREATMENT PLT. ❑ � No. Compartments �r- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. Length of lines FILTER BED Total length/size P ❑ Distance to nearest: Well Foundation I� Property Line SEEPAGE PITS ❑ Depth Size ''SUMPS , - Number ❑ Distance to nearest:-- Well Foundation— DISPOSAL PONDS ❑ 1' 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."Contractors 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." il The applican must call for all required inspections. omp! to drawing On averse side. Signed it Title: Date: OR DEPARTMENT USE ONLY i Application Accepted by p y Date u ` Area Il i Pit or Grout inspection by Date Final in action b � x�_ `I p y � �,,,m,Date 1i+' Additional Comments: II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT`NO. � + EH 13-24(REV.10163) 4 EH 14-26 S vrp