84-1019 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 �,A P.p '�CL�hdivision Name Owner's Name t1J/4-416 !/Y1 Address SA7stG - Phone Contractor's Name License No. 42T:Ll I. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATIOV'E] `SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKi SEWER LINES DISPOSAL FLD. PROP_ LINE FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( ❑ Industrial U Open Bottom []Manteca' Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy } Dia. of Well Casing 17 Public s ❑ Qther " --E Delta � ❑ Type of Casing U Irrigation Approk. ❑Eastern ► Specifications ❑CathodicFProtection Depth Depth of Grout Seal ❑Geophysical r E fs F Type of Grout Er 1 El Other K �� - '"""""'" Surface Seal Installed by O Repair Work DoneType of Pump H.P. State Work Done E Well Destruction ❑ Well Diameter..&O''�" Sealing Material (top 50') i Depth If Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Lf (No septic tank or seepage pitpermittedif public sewer is .----.- � available within 200 feet.) Installation will serve: Residence _✓ Commercial _ Other Number of living units: Nu of bedrooms Lot size Character of soil to depthtof 3 -feet: Water table depth SEPTIC TANK Type/Mfg - �.L G e. Capacity (Q p_ No.• �ompartments _PKG. TREATMENT PLT. E] Type/Mfg Y 'Capacity Method of Disposal Septic Tank ❑ s Distance to nearest: Well - ', Foundation Property Line Destruction Q LEACHING LINE No. & Length of lines Total length/size 7�9 FILTER BED ❑ Distance to nearest: Well Foundation Q ` Property Line SEEPAGE PITS ❑ Depth ) �. Size Plumber SUMPS L ! Distance to nearest: Well,-, Foundation Property Line DISPOSAL PONDS ❑ •_ K k�J I hereby certify that I have prepared this application and that the wark 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-l:icensed,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 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'shal1 employ persons subject to workman's compensation laws of California." The applicant must all for all required inspections. Complete drawing on reverse side. SignedTitle: ;� 1 Date: FORIDEPARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: p o ref. ❑ Lodi 369-3621 Pit or Grout Inspection b Date Ll Manteca 923-7104 Final Inspection by E DateWHaze L 835-6385 Applicant Return all copies to. Enviro en a 'Health Permit/Services 1601 Ave., P.O. Box 2009, Stk., CA 95201 f � FEE BASE AMOUNT<UE AMOUNT REMITTED r RECEIVED BY DATE Ll PERMIT NO. INFO Ly i 10/82 500 EH 13-24 REV. 10/82 ! 14-26