84-949 - Laserfiche WebLink

Home Browse Search

k E APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 '`PERMIT XP1 9;1 YEAR FROM DATE ISSUED mow'' (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit4o construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.5.49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local'Health District. a ' Job Address 1 U 3-0 1 ff..` k I he City AIJ Lot Size PM j Owner's,Name °C CCJ� Address R301 Al - MXc"Ae— Phone S� �- j,r� Contiractor's.-Norrie ;License No. �� / Z Phone I TYPE OF.WELT=/P-UMP. .--r- -NEW WELL --' WELLt--REPLACEMENT'❑ DESTRUCTION-0 - ------ -�^^- „v PUMP INSTALLATION ❑ --�SYSTEM.REPAIR ❑ - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. q-� PROP. LINE FOUNDATION --15:�---AGRICULTURE WELL_�� OTHER WELL PITS/SUMPS,---- INTENDED-USE:- ITS/SUMPS,/INTENDED-USE TYPE bF WELL #PROBLEM AREA CONSTRUCTION SPECIFICATIOfYyS ❑ Industrial �� pen Bottom f❑ Manteca " N Dia.l,of Well Excavation Dia. of Well Casing Domestic/P.rivate t ❑..Grafel'Pack ❑ Tracy Type of Casing' r Specifications o- 0 ❑ Public _. d Other 0.Delta „• Depth of Grouf Seal gsUType of Grout El Irrigation 2_Sa Approx. Depth ❑ Eastern Surface Seal Installed by k Repair Work 7d.,ne ❑ Type of Pump"' H.P. State Work Donp. r i/.'' " Well Destruction. ❑ Well Dia. w Sealing Mater' op 50'1 .. - + Dept Filler Ma al (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ jNo septic system permitted if public sewer is available�within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F y PKG. TREATMENTPLT. ❑ ; Method of Disposal c Distance to nearest: Well Foundation Property Line 9 � t LEACHING LINE ❑ No. & Length of lines Total Iength/s¢e FILTER BED ❑ Distance to nearest: Well't € Foundation Property Line w SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Propety Line DISPOSAL PONDSr ❑ t Q - I hereby certify tkpt,•I-have_prepared_thi"pplication-and-that-the-work will-be-done^ire-accordence�% ith-San Joaquin county ordinances,-state laws, and rules and regulations of the San Joaquin Local Health District, E i Home owner or licensed agent's signature certifies the following:"f-certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman'A 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 parsons subject to workman's compensa- tion laws of California:" N CA The applicant call'fo'i algrei�red"ins ions. Complete drawing on reverse side.` ".A. Signed X �=Tlle: `Date: FOR DEP MENT U E ONLYO �V ✓- :)ta Applicatio epted by fDate )r" Pit Grou spection,by ate ) Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201 FEE{ INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. 1 + EH 13-24(REV:10/89) //� EH 14-26 + �- 'Q o �' Al