84-194 - Laserfiche WebLink

Home Browse Search

Y h 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. TMs 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. 1 _ Job Address / AV s r�/ /g City .S7 - Lot Size .r6 Jf/Q P PM Owner's Name cf /Sj .d [a D _ Xddress cS f � Phone 1`451- 9'O X- Contractor's Name License No. .2-5-41 Phone f6 Q TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ N � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK LINES DISPOSAL FLD.` PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca `4 Dia. of Well Excavation, Q of Well Casing ❑ Domestic/Private ❑ Gravel Pack; ❑ Tracy Type of Casin ❑ Public " ❑ bg Specifrcatiens ❑-Other- . .. e th of Grout Seal r *.-- p Type of Grout ❑ Irrigation -L-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of,-Pump i _ H.P. a J;. State Wotk Done Well Destruction ❑ Wall Diameter 1 1, ' Sealing Material (top 50') ="N � �, - j Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is I .� available within 200 feet.) Installation will serve: Residence Commercial�° Other Number of living units: _ Number of bedrooms P Character of soil to a depth of 3 feet':,-. Lf 1 ' \'\ Water`table"depth O SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `w 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:r Well�_ Foundation !J�Q — Property Line SEEPAGE PITS )RC Depth . :Z J— Size N Number SUMPS ❑ Distance to nearest: Well /lf f l �" Foundation__�! Property Line. DISPOSAL PONDS 1:1 _ 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 fallowing: "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-f©r-which•this•permit-is-issued I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for-all required i spectio s. Complete drawing on reverse side. Signed t w. Title: Date: k - { FOR DEPARTMENT USE ONLY Application Accepted by - - - ---Date A Pit or Grout Inspection by Date =� .Final Inspection by- Date _ � Additional Comme ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: EnvironmentalrHealth-Permit/Services 1601-E-Hazelton-Ave:;P.-O. 2009,ox- Stk.4 4 95201 ` FEEI INFO MOUNT DUE AMOUNT REMITTED CK#CASH RECEIVED BY DATE PERMIT'NO. EH 1324(REV. 10183) Lis , EH 1428 C �7 l