84-1225 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SEF 2 1.1984 , 1601 E..HAZELTON AVE., STOCKTON, CA Telephone (209) 466.-6781 SAN HEALTH. IN LCT L (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in Triplicate) rib cationis ll. the work n desc Application is lance made an�Joaquthe in County Ordinan Joaquin nHealth ce No. District649 for sewage or permit No. 1862 for well/pump and the Rules and (Regulations of he San Joaquin made in compliance Local Health District. ;.M. f . #02�' A' , City Lot Size PM Job Address Owner's Name —-� Address 1 �'7) Phone .5 Contractor's -Name +.4 4,r5 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER If DISTANCE TO NEAREST: SEPTIC TANK SEWER L1NES DISPOSAL FLO. PROP. LINET FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS~� INTENDED USE ❑ Industrial ❑ Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom 11 Manteca Dia. of Well Excavation T of Casing Specifications ❑ Gravel Pack ❑ Tracy Type g Type of Grout — Eastern ❑ Delta Depth of'Grout Seal --Approx. Depth Eastern Surface Seal Installed by Type of Pump DH. P. State Work Done Well Diameter Sealing Material (topi�501 Depth I Filler Material (Below 50') NPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avail blelwit iseptc nepermitted if public sewer is 200 feet Installation will serve: Residence ! Commercial Other Number of living units: Number of bedrooms Water table depth _ Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK E3Type/Mfg Capacity t ,. PKG. TREATMENT PLT. :1_ J, Method of Disposal Distance to hearest: Well "" Foundation Property Line LEACHING LINE FILTER BED SEEPAGE PITS SUMPS El No. & Length of. -lines: = 1- L Total length/size ❑ Distance to nearest: Well � Foundation —Property tine ❑ ',` `Size Depth Number Well AA ' Foundation Property Line _ ❑ . Distance to nearest: 0) 0 r., 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, 1 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." F a The applicant must call for 1 required inspections. Complete drawing on averse side. ` Title: Date: Signed FOR DEPARTMENT -,USE ONLY A _7\ %L_\ Area Date Application Accepted by Pit or Grout Inspection by Date Final Inspection Date 1�. Additional Comments: 0 Stk 466-6781 C3 Lodi 369-3621 ❑ Manteca 8x3 7104 ❑ Tracy 83 Applicant - Return all copies to: Environmental Health PermitlServices 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4�RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED O INFO + EH 13-24 MEV, EH 14-28 5- 3 H I (�—�