84-990 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR,PERMIT R-DSAN JOAQUIN LOCAL HEALTH DISTRICT 1,E.HAZELTON-AVE.,�STOCKTON, CA AUG 6. 1984 ` Telephone [209} 466-6781 i t 1-,_. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SHEALAN OT Q STRICT ,in _ (CompleteTriplicate) .. I e no No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San JoaqOrdinauin Local Health District fo made in compliance with an Joaouin,Couty ra permit to construct an install the work herein described.This application is SY � Local Health District..4._� , 4,. : iD:* PM /LC! f Lot Size Y � City Si _ x- Job'Address I- Phone G �- Address / Owner's Name Phone 20�4 icense No. Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ t SYSTEM REPAIR PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES _�� PITSIS.U_MPS DISTANCE TO NEAREST.:)SEPTIC TANK � AGRICULTURE WELL __ OTHER WELL �— FOUNDATION---- - - (TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing INTENDED USE ❑ Manteca Dia. of Well Excavation ❑ Industrial z ❑ Open Bottom Specifications i ❑ Tracy Type of Casing M DomesticlPrivate ❑ Gravel Pack Type of Grout ❑ Other ❑ Delta Depth of Grout Seal , j ❑ Public Eastern Su ce Seal installed by y El Irrigation �Approx. De State Work Done H.P. F Repair Work Done'M.E�1Type of Pump � Well Diameter Sealing Material (top 50'1 Well Destruction ❑ Filler Material (Below 501 1 Depth 1 i available within 200 feet.)- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (NO septic system permitted if public sewer is I Commercial— Other-- Installation will serve:, Residence Number of living units: Number of bedrooms� Water table depth � A Character of soil to a depth of 3 feet:" Capacity� No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal M PKG. TREATMENT PLT. ❑ Foundation Property Line�— { Distance.to nearest: Well f Total lengthlsize ( LEACHING LINE ❑ No. & Length of lines Property Line r= FILTER BED Ll Distance to nearest: Well Foundation 4 Size Number SEEPAGE PITS ❑ Depth Property Line Foundation�� SUMPS ❑ Distance to nearest: Well --DISPOSAL PONDS ❑- ' �� l 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 r rules and regulations of the San Joaquin Local Health following: become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Home owner or licensed agent's Joaquin certifies the District. in 1 certify that in the performance of the work for which this permit is issued, 1 she no r employ any person in such manner as to certifies the following:"I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compen - tion laws of California." applicant call for all re wired i spection . Comp) rawing on reverse side. The app Date: Title: Signe - ' ( FOR DEPAR MENT USE ONLY Q Date �+ y Area /f ate Date Application Accepted by ab Final Inspection by Pit or Grout Inspection by — Additional Comments: ❑ Manteca 823-7104. ❑ Tracy 835-6385 C1Stk., CA 95201 Applicant- Return all copies to: Environmental HeaStk 466-6781 ❑ Lodi 369 3611 lth Permit/Services 1$01 E. Hazelton Ave., P.O. Box 2009, CK RECEIVED BY DATE PERMi7`N0. FEE AMOUNT DUEAMOUNT REMITTED CASH c r INFO 1 e ViV Z r EH 13-24 IREV.101831 Lis o � EH 1428