84-1037 - Laserfiche WebLink

Home Browse Search

I r APPLICATION FOR PERMIT SAN ]OAQUiN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin LocaI' Rea Ith District for a permit to construct and/or install the work herein described. This application is madeiin compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I and the Rules and Regulations of the!San Joaquin Local Health District. • Subdivision Name Job Address Phone 23V 3:ZAn Owner's Name Address 1 Phone Contractor's Name MOO JAYA 1s TYPE OF WELL/PUMP WORK: NEW 'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [] ��J4fCE�J ISTALLAT10N SYSTEM REPAIR ❑ OTHER N ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FCD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Lf Open Bottom ❑ Manteca Dia. of Well Excavation 6omestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Delta ❑ Public Other ❑ Type of Casing Irrigation Approx. E] Eastern Specifications F-1CathodicProtection Depth Depth of Grout Seal ❑Geophysical k Type of Grout ❑Other Surface Seal Installed by Jq//TH Repair Work Done ❑ Type of Pump f 5vR_ H,p. State Work Done Well Destruction❑ Well DiameterSealing Material (tap 5O') Depth f Filler Material (Below 50') �} i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit avaeilableed if withinu200cfeet.) is LA i Installation will serve:- Residence , Commercial Other Number of living units:/, Number of bedro6ns Lot size Water table depth Character of sail to`a-depth of 3 feet: No, Compartments S }'- Capacity _ SEPTIC TANK i ❑ ,!ype/Mfg' 's Capacity Method of Disposal r PKG. TREATMENT PLT. ❑ Type/Mf�gf Propert Line SEWAGE SYSTEM Distance to nearest: Well Foundation y DESTRUCTION ' ❑ e i 0 Total length/size LEACHING LINE ❑ .No. & L'ength of lines FILTER BED ❑ -Distance to nearest: Well Foundation Property Line f� •`� Number i SEEPAGE PITS ; ❑ Depth Size SUMPS ❑� Di"stance to nearest: Well Foundation��Property Line DISPOSAL PONDS � "•�J .- I hereby certify that I have,pre`p red 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. I Home owner or licensed agent's s gnature certifies' the fo-llowi-ng. "I_certify that in the performance of the work for which this permit is issued, 1 shall not; employ any'pers'on in such-manner-as to become subject to workman compensationlaws ofwthe fwork�for nwhich Contractor's hiring or sub-contracting signature certifies the following: I certify that in the p this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant al for all required inspections. Complete drawicn�on reverse IF side. Date: d Signed X Title: � _'/// � �� �. PARTMENT USF ONLY ® Ct+k 456-6181 YI/ ea x2 Application Accepted by ❑ Lodi 369-3621 { Additional Comments:!E Date ❑ Manteca 823-7104 Pit or Grout Inspection by Tracy 835-6385 Final Inspection-by Date aa Applicant - Return all copies to: . E �nment.l Health Permit/Services 16D1 E. Hazel nn AJ '.�, P:O. Box 2009, Stk., CR 95201 i I DATE PERMIT N0. f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO r`- ti 10/82 50o. E �J �`[ EH 13-24 REV`. 10/82 :.'