84-749 - Laserfiche WebLink

Home Browse Search

ii APPLICATION FOR PERMIT I I� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA AN 51984 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCAL (Complete in Triplicate) HEALTH DISTRICT 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 � r�[%�7 City ,/ P S9 PM �! its i Name Owner's Namddress //t�'� ✓�.P� Phone { Contractor's-NameII b/+ se Na. �G 3 ! Phone V611 <1:i TYPE OF�WELL/PUMP; NEW WELL ❑ / WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION-.-[1l -_ ,,, _ _SYSTEM REPAIR. OTHER EJ_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Ind trial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing n I L�!'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications sj ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation / �i Approx. Depth ❑ Eastern Surface Seal Installed by W Repair Work Done 1� Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material /top 501 ! Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i II available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other Number of living units: II Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line k II. SEEPAGE PITS ❑" Depth Size Number SUMPS = ❑ Distance to.-nearest: Well'- Foundation-°-- _ •Property Line 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 licen nt'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pars in such nner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the f wing: "I ce that in the performance the work f which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of alifor The appli nt mus or 1 req d ' omplete d wing on rave side. d 6 J s Signed � '� -��'' Title: � -�/� Date: FOR DEPARTMENT USE ONLY Application Accepted by �'�MC r E Date lr7 `4 v ` Area [� M p Pit or Grout Inspection by Date Final Inspection by Datey Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM/OUINT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. EH is IREv.101M)