84-746 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA K Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x d t (Complete in Triplicate) t 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. �A_9 Job Address r Ci Lot Size PM � Phone - Owner's Name Address t2i Contractor's Name ense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL' 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ., Dia, of. ell Excavation" ` Dia, of Well Casing Domestic)Private Gravel Pack Tracy '--T,ype of Casing `. Ll © ❑ 1k Specifications I { e y I © Public El Other j ❑ Delta Depth of Grout Seal �� Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H .P: — -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501, Depth •I Filler Material (Ellow 50'N___ 's TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION --'DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence .�Commercial— Other Number of living units: Number of bedro ms Character of soil to a depth of 3 feet: # Water table depth SEPTIC TANK Type/Mfg Capacity No. compartment,;; PKG. TREATMENT PLT. ❑ Method of Qjpol pistanc to nearest: Well Foundation/ Property Line= — LEACHING LINE No. & Length of lines ^' A^Total length/size`""' [ r , -`� ! FILTER BED Distance to nearest: Well Foundation .— Property Line.—.,,. .I i SEEPAGE PITS Depth I Size N ber SUMPS ❑ Distance to nearest: Well Foundation Property Line' -� DISPOSAL PONDS ❑ � f I he certify that I have prepared this application and that the work will be done iris accordance with San Joaquin county ordinan ces, 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's compensation laws of California." Contractors 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." I . k et tl TII The applicant mu t c or all requir spections. Compl drawing on terse side. (/j�T t Date: f i Signed I Title: R DEPART ONLY r // Application Accepted by ! + Date 6 'A Alr r PP P � )' Pit or Grout Inspection by�` Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 pApplicant- Return all copies to: ,Egnvirroonmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sttk..,-CCA 95201 J�0 CCj/jp I Z,0/1 CX/�[{✓��S � �`l � rl4j�-r�J /�� J r FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH `' +EH 13-24(REV.10183) >�--.�- , A C., �! i g-� y e EH 14-26