84-912 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.., STOCKTON, CA Telephone Q091 466-6781 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 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,Flag ulations of the San Joaquin Local Health District. �j y�� Job Address 72 Q 'r �OTS T� i ;r/ City` Lot Size PM ale Owner's Name `l Addre936 � � d� 4`C��[-a'Q� rd rcn Phone � I" , 41L� Contractor's Name P",- License No. 6 Phone c, a " 3 , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom 171 Manteca Dia. of Well Excavation IDia. of Well Casing Q'Domestic/.P-rivate-.---O-Gravel-Pack,-f ❑ Tracy-- -Type•of Casing - - - - - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. DeptV ❑ Eastern Sprface Seal Installed by t1 Repair Work Done E:1 Type of Pump H.P. , )/ , State Work Done P,�[ d-+%� + Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/-ADDITION'7-1DESTRUCTION13 (No septic system permitted if public sewer is available within 200 feet.) Q� Installation will serve: Residence_ Commercial_ Other 's W Number of living units: Number of bedrooms Charaotei of soil to a depth of 3 feet: Water table depth, SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V" SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; 1 hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquin county ordinances, state laws, andp rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l 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."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 persons subject to workman's compensa- tion laws of California." The applicant myQcall or all r inspections omplete�draJwing on reverse-side. Signed X Date: 2�� FOR DEPARTMENT USE ONLY ``// ��JJ , Application Accepted by � -.4 - Date �%p�JrJ�� Area �j Pit or Grout Inspection by Date Final Inspection by �� '�/� [ Date g Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.10!831 S o -76 EH 4428 11