84-480 - 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 i 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 dy} Local Health District. Job Address 7j ZIZ C1,1 n2a ' -�� City "-.4 O;W Lot Size fi CISe'9C-a PM Owner's Name CAZ Address 5'f.�/16C —_ Phone J ,1 Contractor's Name lfly �S'�y -License..No. e`sy"",s��/.� Phone n TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Z; rte,-.^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 (top 501 Depth ..Filler Material (Belo '1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is a, available within 200 feet,) Installation will serve: Residence CommercialOther Number of living units: __/_ Number of bedrooms '" r Character of soil to a depth of 3 feet: G X,09 X -e &ggo Aul Water table depth SEPTIC TANK E""Type/Mfg _l�Aldic Wt Capacity, 36 00 No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal / 'F Distance to nearest: Well 1 0 o Foundation 'Z o d, Property Line LEACHING LINE �� `khr� No. & Length of lines _;Z — All, t Total length/size ©� X FILTER BED 0', ' Distance to nearest: Well„ OLS Foundation f Property Line SEEPAGE PITS e-- Depths'' 2 5�j Size Number �- SUMPS '`• ❑ Distance to nearest: Well 260 ' Foundation-;: 7Property Line i DISPOSAL'PONDS ❑ i I hereby certify that I have prepared this application and that�t6e 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 61 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 call for all required Complete drawing'on reverse side. — Signed X ► - Title:^� - Date: T. FOR DEPARTMENT USE ONLY Application Accepted by (� ++.. A Date Area �p Pit or-Grout-inspection-by c".," Date -Final Inspection by Date i Additional Comments: ' ❑ Stk 4664781 ❑ 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 I �,� ..•..,.�--sem—�..,.�....�_ �.._ � � - .-.- - .� .,_.,... .. ._..- v.� FEE AMOUNT DUE ' AMOUNT REMITTED CK T RECEIVED BY DATE PERMIT'NO. INFO CASH +EH 1324(REV.10183) �•l.. -. 1'`. �;''".... ' ��V U.'- -.4 ` �� -'t e—( D EH 1428