83-321 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HE".LTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. C3•� Telephone (209) 466-6781 11 I DATE ISSUED � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w E: (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 ( Jr Subdivision Name Owner's Name _ # Address �v g E Phone E3 I 7S Contractor's Name I License No. phone y[ .2_r .r9 TYPE OF WELL/PUMP WORK: NEW.WELL EJ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ft O. PROP. LINE w FOUNDATION " AGRICULTURE WELL OTHER WELL PITS/SUMPS -- —_. —INTENDED_USE _ _=TYPE._OF WELLROBLEM.-ARE_A CONSTRUCTION SPECIFICATIONS 1J F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing 9 ❑ Public ❑ Other [ Delta Type of Casing 77, irrigation Approx. Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done D Type of Pump _ H.P. / State Work Done P�1u 3 Well Destruction ❑ Well Diametert Sealing Material (top 50') — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑j Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distancefto nearest: Well . Foundation Property Line I DESTRUCTION y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 it 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 workmang compensation laws of California." he following: "I certify that in the performance of the work for which Contractor's hiring or sub-contracting signature certifies t 9 „ l this permit is issued, I shall employ persons subject to workman's compensation laws of California. The applicant must call fora W required inspections. Complete drawing on reverse side. Signed X Title: Date:S FD PARTMENT USE ONLY � Stk 466-5781 Application Accepted by Area _ i Additional Comments: ❑ Lodi 369-3621 E Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT-EE PERMIT N^0. INFO -� � 93 93-3c j � la/s2 Sao EH 13-24 REV, 10/82 14-25