84-580 - Laserfiche WebLink

Home Browse Search

I APPLICATIONrFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZUTON AVE.,`STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) p II 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 '� Zee,-YA/ City SLot Size 1'0 e_ X 1" PM Owner's Name Contractor's Name /�.r9/�/�/1'AY �`S��'s License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 � EJ Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L] Tracy Typa of,Casing � - Specifications 'w ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal—L—'"— Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface-Seal Installed by = �' Repair Work Done ❑ Type of Pump H.P. ""- `"' Stata~Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below ,) b TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION❑ (No septic system permitted if public sewer is f I, .available within 200 feet.) -.. Installation will serve: Residence t Commercial_ Other +ate Number of living units:_,1— Number of bedrooms. Character of soil to a depth of 3 feet: Z_ iq Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest:, Well Foundation Property Line I � LEACHING LINE No. & Length of lines O - Total length/size � �! FILTER BED ❑ Distancesto nearest: Well IV,4\ ;;:Foundation^Z0 Property Line f SEEPAGE PITS Depth Size - E Number ` > SUMPS El Distance to nearest: Well IVA Foundation Property Line —5- DISPOSAL PONDS ❑ !.✓ �� j i I hereby certify that I have prepared this applicatioA 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'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 employp brsons subject to workman's compensa- tion laws of California." The applican t call for all required inspections-Comptete-drawing-on-reverse-side: ' Signed Title: _ -- Data: FOR DEPARTMENT USE ONLY Application Accepted by v _ Dat �� Area �2 lr Date Pit or Grout Inspection by Date 1 /final Inspection by I ( . I Additional Comments: ❑ Stk 466-6781,/'" ❑ Lodi 3W3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental-Health-Permit'/Semites-1601-E7-Hazetton Ave;•'P:O-Box-2009,-Stk-CA-95201 t FEE AMOUNT OUE AMOUNT.REMITTED.� CK# .RECEIVED BY L•DATE PERMIT"NO. INFO e. , . < :"`CASH � ECE {`[ g� ! { + EH 13-24(REV.10/83) L' 5 } C +' l�f'O J � ('mss go EH 14-26