84-1408 - Laserfiche WebLink

Home Browse Search

t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE:, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) 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 - "t7 L(l City ( ""( Lot Size PM Owner's Name �i Address 7�� 99 Phone Contractor's Name License No. 2,crl Z Phone TYPE OF WELL./PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONI( AGRICULTURE WELL OTHER WELt PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS } ❑ Industrial �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of Well Casing ❑ Domestic/,Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ;; ❑ Delta - Depth Grou of t Seal Type of Grout ❑ IrrigationApprox. Depth ❑ Eastern __ '• Surface Seal Installed by f Repair Work Done ❑ Type of Pump I H:P. State Work Done 6 Well Destruction El Well Diameter I 'Sealing'Material Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADOITiON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedroo s Character of soil to a depth of 3 feat: I k� Water table depth �p ✓ SEPTIC TANK ❑ Type/Mfg t Capacity k,No: Compartments PKG. TREATMENT PLT. ❑ -` , Method of Disposal I Distance to nearest: Well Foundation Property Line '1. LEACHING LINE ❑ No. & Length of lines'' —_; = Total'-le''igth/size----•— FILTER BED ❑ Distance to nearest:,Well Foundation t Property Line s f y SEEPAGE PITS Depth �5/Size Number .s. SUMPS ❑ Distance to nearest: Well 'ae Foundation Property Line_-... DISPOSAL PONDS ❑ I hereby certify thatl'have prepared this appiicaiion and[hat the work will 6e done'ii 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 l 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." The applica=ustfor all r 'red inspections. Complete drawing on reverse side. Signed Title: 144.dl Date: _ /,P— FOR dam"FOR EPARTM NT USE ONLY ' Application Accepted by " u Date Area Ai Pitt r Grout Inspection by Date /Final Inspection by Date lL�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environm{p{ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -b i FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY 1 DATE PERMIT"NO. + EH 3-24 EH 114-26IREV.101631 `�S —61A Li