84-1134 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERIiI i SAN JOAQUi" LOCA! HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA +��Y/� PERMIT NO. Telephone (209) 4666781 W PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate), j�_7- •r C-47% I& 1 7 4L` 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 Regulati cina of the San in Local Health District. Job Address L7 /t C/� Subdivision Name Owner's Name dress.. Phone Contractor's Name License No. Phone �� TYPE OF WELL/PUMP WORK: NEW'WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION / SYSTEM REPAIR OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOJNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ljIndustrial ❑ Open Bottom Manteca Dia: 'of Well Excavation ' ❑ Domestic/Private ❑ Gravel Pack Tracy Dia",of Well Casing ❑ Public ❑Other Delta' Irrigation Approx. Eastern Type of Casing F—ISpecifications Depth Cathodic Protection P r Depth of Grout Seal 1-1 Geophysical ❑Other Type of Grout _ `* Surface Seal Installed by Repair Work Done ❑ Type of Pump t H.P. +�� State Work Done Well Destruction ❑ Well Diameterl Sealing Material (top 501) Depth ! Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table-epth [� SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg r Capacity Method of Disposal SEWAGE SYSTEM Distance.to nearest: Well Foundation Property Line DESTRUCTION ❑ ) LEACHING LINE ❑ No. & Le4gth of lines Total length/size FILTER BED Distance?to nearest: Well Foundation Property Line SEEPAGE PITS Depth i Size Number SUMPS L1 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 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 compensation laws of California -" Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic t tail f all r d' insp io s - mplete drawi on r de-.— �r � Signed X 6� Date: !P — FO PARTMENT USE ONLY Application Accepted by Area ❑ Stk 44-6781 Additional Comments: Lodi 369-3621 'Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date (QRZ L7 Tracy 835-6385 Applicant - Return all copies nvironmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, Stk.,"]CA;• '95201 .ta - FEE BASE AMOUNT DiL AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. 1 INFO �s. IRLJ-1 III EH 13-24 -REV. 10/82 10/82 560 14-26