84-524 - Laserfiche WebLink

Home Browse Search

M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED S�� 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 Sar Joaquin LocalHealthDistrict. Job Address W (� 7Q ) �J Subdivision Name Owner's Name % Address Phone Contractor's Name ,d �r(� FULGc License No. `J Phone T TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ- 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 ❑ Domestic/Private ` ❑ Gravel Pack ❑ Tracy Dia, of Well Casing \ ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. Eastern Specifications CathodPttion Depth ❑ ' Protection r Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal In5tajled by Repair Work Done ❑ Type of Pump H.P. State Work Done'.' � Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth i Filler Material (Below 50') { s TVPE--OF—SEPT-IC�-WORK:--•NEid-I445TAL�-AT-I-9t�-;r-itE�,4�f•AEl�i�fBN�—(:Ne-septic�snk�rr_s ,e--Fia�t�permit-t-ed i-�--pabl_it3s�war--,�i� --,.•-,..� r. * { available within 200 feet.) ; Installation will serve: Residence _ Commercial Other Y. Number of living units: Number of bedrooms Lot size r i Character of soil to a depth of 3 feet: ! Water table depth ' SEPTIC TANK ( Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ size len th Total LEACHING LINE � No. & Length of lines �3`- � 9 / , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I 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§ 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 compensation laws of California." The applicant must call f all ired i spec tions. Complete drawing on reverse side. Signed X r .,, •" T1tle`. Date: } FO EPARTMENT USE ONLY "7 ❑ Application Accepted by Area e Stk 466-fi781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout lnspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT .DUE AMOUNT REMITTED RECEIVED BY OAT PERMIT NO. INFO-r10/82 500 EH 13-24 REV. 10/82 14-26