84-1016 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. '7,02-3 �r C, ' ^ s Job Address _- 3 �tZ2� 0EN � 4-w-p— _ City ----7 �� Lot Size_�'0 i X PM Owner's Namegni P Address Phone. Contractor's Name __L5i�'-t� License No. ��D _ Phone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ a DESTRUCTION ❑ 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 LI-Tracy- Type of Casing Specifications_ ❑ Public ❑ Other ❑ Deltaj Depth of Grout Seal T ype of Grout - ❑ ---Approx.Approx. Depth F1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction F1Well Diameter Sealing Material (top 501) Depth Filler Material f8elow 50'i� (n TYPE OF SEPTIC WORK: NEW INSTALLATION AREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic-system.permitted if public sewer is V ' t11 .r - available within 200 feet.! Installation will serve: Residence-X_ Commercial_ Other Number of living units: _ Number of be&aoms 341i Character of soil to a depth of 3 feet: r ry t Water table depth SEPTIC TANK ,lei Type/Mfg i f Capacity—csa-- No. Compartments ti..» ' PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well ' 5 2 v Foundation c�C7 —. Property Line s7 0 LEACHING LINE A No. & Length of lines '4e S Total length/sizef FILTER BED ❑ Distance to nearest:- Well 1 0P f Fouridatidn_� '� property Line SEEPAGE PITS Depth _ � r, Size Number SUMPS ❑ Distance to nearest: Well.1bA' Foundation +-L;b _ Property Line DISPOSAL PONDS ❑ 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 req i inspec 't5ns. Complete drawing on reverse side. Signe C�/111�• �/ Title: Jl r Date: �! FOR DEPARTMENT USE OAU Application Accepted by Date 3 �r Area q� k Pit or Grout Inspection by Date 1 C7 [ V Final Inspection by Data .Q a j Additional Comments: ❑ 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* F • -INFO -- CASA-- . RECEIVED BY DATE +�iRJXA{REV.10!931 Eu. EH2at IS