84-849 - Laserfiche WebLink

Home Browse Search

APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601, E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)`466-678141T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 city � r Lot Size4 PM Owner's Namef°YAd ressa-�f.�I ,/ Ac�'/!',�/�•�— r1'1Phone { Contractor's Name dr/w�hf License No. � 746, / J Phone � TYPE OF WELL/PUMP: NEW WELL-J-4 WELL REPLACEMENT ❑ DESTRUCTION ❑ , ' _ —PUMP INSTALLATION L i "' Sl(STEM REPAIR"❑---- ----- —OTHER ❑•L DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES IdO 4— DISPOSAL FLD. PROP. LINE { FOUNDATION _L0L�-'1r`AGRiCbLTURE WELL OTHER WELL PITS/SUMPS�Sa INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS--'" ❑ Industrial ❑ Open Bottom ❑ Manteca 1 Dia. of Well Excavation 1 �.j�.1-�' Dia. of Well Casing `I �mestic/Private Z,6I Pack CJ Tracy Type of Casing Specifications F ❑ Public ❑ Other„ ❑ Delta k Depth of Grout Seal _ Type of Grout I '! ❑ Irrigation ___4pproz, pe5pth _p Eastern1 Surfs a Seal Installed by Repair Work Done ❑ Type of Pump � PG, !' State.Work Done Well Destruction ❑ Well Diameter ' Sealing Material:top 50'.p� .(t P,Depth Filler Maferial IBelow 50'), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ';REPAIR/ADDITION LJDESTRUCTION ❑ (No septic'system permitted if public sewer is =t`.' - " o available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity °No Compartments PKG. TREATMENT PLT. ❑ WMethod of Disposal j Distance to nearest: Well Foundation Property Line r` f LEACHING LINE ❑ No. & length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line p ' SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line # DISPOSAL PONDS ❑ f 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 r 'rules and regulations of the San Joaquin Local Health District. F !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, 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." r The applicant m t c f r quired inspections. Complete drawing on reverse 91qe. ,I j r }Signed itle: `"� �"�' Date: / Z r ' FOR DEPARTME USE ONLY s Application Accepted by Date Area s � Pit o Grout nspection b pX Date r w Final inspection by Date Additional Comments: _ ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 ° . r :Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE - AMOUNT DUE AMOUNT REMITTED DK RECEIVED BY - DATE l'ERf4lIT`NO. -' INFO t. 'CASH'' + EH 1324{REV.10!831 L g � EH 14-28