84-380 - 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) J 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 City f Lot Size A AC!"�_ PM Owner's Name Addressp '��. �17l/�2 , AI/ A',. Phone Contractor's Name ////! V C:t License No. � u _Phone_ TYPE OF WELL/PUMP: NEW WELL ;K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0- DISTANCE TO NEAREST: SEPTIC TANK �,6c / � SEWER LINES arO e DISPOSAL FLD�� PROP. LINE —FOUNDATIONS AGRICULTURE WELL OTHER WELL/PITS/SUNIPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-, tit 7/ ❑ Industrial ❑ Open Bottom N Manteca Dia. of Well Excavation 40 �l Dia. of Well Casing j Domestic/Private.. - j�l Gravel Pack, C1Tracy Type of Casing' 4/2,S'S 1�6 Specifications I ;� ❑ Public , "",.`, �OwOther_ "; ❑.Delta Depth of Grout Seal ;' � Type of Grouts ❑ 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 (top Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ` Number of living units:' Number of bedrooms� "� �, 6S Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line \3 LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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:,"1 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," f' The applicant rpust call for all required inspections. Complete drawing on revers side. Signedl'; Title: Date: ' OR PARTMENT USE ONLY �/ Application AcFments: Date / � � Area ]I Pit or Grout InDate — ' Final Inspection by __ /A Date Additional C ❑ 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.Q. Box 2009, Stk., CA 95201 FEE INFO . AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO." + EH 13-24 MEV.10183) Li EH 1428