84-444 - Laserfiche WebLink

Home Browse Search

loll APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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 Local Health District. ` Job Address 7L fib moo» 5 City LCSCQ16ALot Size a C- - PM Owner's Name —�n n L-��1Y1 iSa � Address ??a 4 J/D,2 4?94rlrsv Ae. Phone ff Ir Contractor's Name 2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK 1 1SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I # AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL # PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 1 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑j Other C1-Delta Depth of Grout Seal Type of Grout C� ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Instailed by ~` ' Repair Work Done ❑ Type of Pump .f # H.P. State Work Done Well Destruction ❑ Well Diameter 1 ;tiSealing Material (top 501 Depth—1--4 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i I - '. available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Numberiof bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity'/�Qp No. Compartments PKG. TREATMENT PLTMethod of Disposal r Distance to nearest: WeIIA9W '� i'Foundation`—'Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line l SEEPAGE PITS ❑ Depth -Size { 2 Number SUMPS Distance to nearest: Well Foundations Property Line ! DISPOSAL PONDS L ❑ L 00 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's compensation laws of California.- Contractors 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." I The applicant must call for all required inspections. Complete drawing on reverse side. t Signed X �-__/ Title: Date: " FOR DEPARTMENT USE ONLY Application Accepted by Date �` Area . Pit or Grout Inspection by Date Final Inspection b Date — 2� Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO FEE .. A�MOO/U[NT'DUE. AMOUNT REMITTED CASH CK 0 RECEIVED BY (� DATE PERMIT'N.O..' + EH 13-241REV.101835 �., "1 (� C� - N� -1 -�(L} - ry� EH 1428 1