84-369 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone {209) 466-6781 a+< 13 Y,0 3 PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health.District for a permit tb construct and/or install the work herein described. This application is ll/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we Local Health District. Job Address pp 1 t City l Lot Size ` s E P_r4\ 1---� Address —sf\YV1 Phone Owner's Name _ ,, ._.------�,.� � Phone Contractor's Name I License No. 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE - -FOUNDATION AGRICULTUREWELL___ � OT.HER WELL,, -- -PIT.S�SUMP_S_ �-—�- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing,— F1 i Type of'Casing_ Specifications ❑ Domestic/Private ❑ Gravel"Pack"'""""""❑ Tracy"'"'"" ❑ Public EJ Other F ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -Approx. Depth E] East Surface Seal Installed by E _ H.P. State Work Done + Repair Work Done L1 Typo of Pump ; Well Destruction ❑ Well Diameter ,'Sealing Material ttop 501 _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EJ REPAI R/ADDITION ElDESTRUCTION'❑ (No septic system permitted if public sewer is available within 200 feet.) CO e� r Installation will serve: Residence Commercial, Oth Number of living units: �' Number of bedrooms j Character of soil to a depth of 3 feet: t Water table depth -- achy _ No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well Inh �Foundation / Property.,Lin� x oOr7 �C4otal length/sizeL, LEACHING LINE l�No. & Length of line � `' _ T v_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS "�` epth —,�. �—Size—.; Number ' SUMPS El Distance to nearest: ' ryWell' 1 Foundation Property Line .DISPOSAL PONDS ❑ 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. III Home owner or licensed agent's signature certifies the following: "(_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#o workman's compensation laws of California-" ploy er osnshiring subject to wosub-contracting compensa- t certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ pe 1 i I tion laws of California." h - TS�gap must a ora equir dinspections. Complete drawing on reverse side. P 1 - Titlg: Date: S I FOR DEP TMENT USE ONLY Application Accepted by V� Date l� Area r Final Inspection by r Date Pit or Grout Inspection by Date d ~ f ( n f Additional Comments: ` 13 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104-, ❑ Tracy 83155365 ' Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Avg., P.O. Box 2009, Stk., CA 95201 # f FEECK RECEIVED BY DATE PERMIT•NO.' INFO AMOUNT DUE AMOUNT REMITTED GASH 71,[T /Q— __ + EH 1324(REV.10183) ter- `3 FFF EH 14-26 _.....