84-1241 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 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 withoa Joaquin County Ordinance No.549 for sewor No. 1861 for welt/pump and the Rules and Regulations of the San Joaquin Local Health District. r,-tl� P Job Address 411)C'`' 41_ City Lot Size 3, )7d? /lcl. PM Owner's Name L,-Ijt.Ale,h e Z4 Address Phone Contractor's Name 7Lr License No. _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 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 (tap 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION t] (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J_ Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK °j� 'Type/Mfg Capacity-gQOLf No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 166 Foundation -2s Property Line ?r LEACHING LINE No. & Length of lines _._. Total length/sizee� FILTER BED ❑ Distance to nearest: Well Foundations Property Line jj3e�*� � I SEEPAGE PITS r� Depth - I Size ILI i { Number j SUMPS ❑ Distance to nearest: Well Z 3 42 Foundation J411 e9 Property Line DISPOSAL PONDS 0 J I hereby certify that f 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 agents 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: "f 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, all for all required inspections. Complete drawing on reverse side. 4 { Signed s --�� Title: ° bate: FOR DEPARTMENT USE ONLY Application Accepted by Date Z5 Area 0� Pit or Grout Inspection by Datet G ' Final Inspection by Date $ r �y� t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 1324(REV.10183) c EH 14-26 s