84-1434 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT All, 1601 E. HAZELON ON AVE., STOCKTON, CA 09 +1 Q Telephone l2 f 466-6781 V B ~ 1884' PERMIT EXPIRES 1 'YEAR FROM DATE.ISSUED �1V i (Complete in Triplicate) + ��JO Q�;ii'>1 L Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TF�isst'afili;ration is made in compliance with San Joaquin County. Ordinance No. 5499 for sewage or No. 1862 for well/pump and the -Rules and Regulations of the San Jdaquin , yrt 1•: ;�. F �e3•'`.Gs :A. < -IY al:: E.o " .C.; Local Health District. Lot size PM Job Address`' .. , . . City - _ 1 �_ Address Phone Owner's Name n� / Phone / Ytn c��►-1 a y License No. r Contractor's Name — - TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑, DESTRUCTION ❑ # r.. _ PUMP INSTALLATION ❑. y SYSTEM REPAIR .[yx OTHER ❑-- - DISTANCE. TO NEAREST: SEPTIC TANK,SEWER LINES DISPOSAL FLD. PTS/ LINE FOUNDATION:AGRICULTURE WELL OTHER WELL- -PITS/LINE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECII=IC_ ATIONS- Dia, of Wel! Casing ❑ Industrial, ❑Open Bottom ❑Manteca dia.•�of-Well-Excavation-- � - • ' Type of Casing Specifications [1-Domestic/Private ❑ Gravel Pack ❑Tracy 7 of Grout El Public ❑ Other ElDelta Depth of Grout Seal Type ❑ Irrigation ---Approx. Depth L3 Eastern Surface Seal Installed by 6 ry State Work Done -� 1 Repair Work Done ❑ Type of Pump - H P' 0 1 Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth 1 Filler Material (Below 501 r" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system m perm+esti `ed if public sewer is. available Installation will serve: Residence Commercial _� Other } tr%; Number of living units: Number of bedrooms f R ._„ ; Water -table depth-""""'""" Character of soil to a depth of 3 feet: t. SEPTIC TANK ❑ Type/Mfg Capacity -'No:-Compartmen ts �; �•. Method of Disposal•• • .I PKG. TREATMENT PLT. ❑ �c� [ j Distance to nearest. Well Foundation - Property ,Line• ' Total length/size LEACHING LINE ❑ No. &Length of lines FILTER BED C1 Distance to nearest.- Well Foundation Property Line SEEPAGE PITS ❑ Depth Size SIJICAPS ' ° ,❑ Distance to n� earest Nlell !Number _ tdation''`�' � ' � Property Lie t ,S,a'u 1 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. 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 o workman's comb4nsation laws of California." Contractor's hiring or sub -contracting signature employ any person in such manner as to become subject t certifies the following: "1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa tion laws of California." Theapplicant m st all all required inspections. Complete drawing .on re side. Signed f Title: —� r It i3tls _ Date- FOR DEPARTMENT USE ONLY Application Accepted by — Date Area—= 1 ../1„GQ� __ Date Pit or Grout Inspection by Date Final Inspection by w Additional Comments: ❑ Additional 4l Com 1 ❑ Lodi 369-3621 l 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 J IFEE NFO AMOUNT DUET AMOUNT REMITTED CK RECEIVED BY DATE' PERMIT"NO. �- + + '+ EM 1324 1REV. 101831 EH 14-28