84-765 - Laserfiche WebLink

Home Browse Search

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) I 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 .549 for-sew' or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Courtly Ordinance No Local Health District. r � s t City Lot Size PM Job Address Y Owner's Named Address Phone fCF �. �y 9 S Phone Contractor's Name -) ' License No. TYPE OF WELL/PUMP: NEW WELL 0' WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El a DISTANCE TO NEAREST: SEPTIC TANK• SEWER LINES DISPOSAL FLD. ' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED'USE W.YPE OF WELL PROBLEM AREA, CONSTRUCTION.SPEC:Ii:kCATIONS F - E1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done .S Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: ' NEW INSTALLATION ❑, RE`PAIR/ADDITION ❑ DESTRUCTION ❑ a o septic sy irtem rmiitted if public sewer is 1/� ` Installation will serve: Residence✓ `ommercial ther ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: NQ Water table depth SEPTIC TANK J1'Type/Mfg Capacity Uy No. Compartments PKG. TREATMENT PLT. ❑ Method of Disppsal r Distance to nearest: Well� Foundation�Q Property Line r LEACHING LINE u o• & Length of lines a& d Total length/size A 1 FILTER BED ❑ Distance to nearest: Well 1&2 Foundatio Property Line SEEPAGE PITS ❑ Depth f Size Number .. SUMPS ❑ 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 parson 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 sub iect to workman's compensa tion laws liforni The app scant ust for all r nspecti ns. Complete drawing on reverse side. 3 Signed Title: Date: FOR DEPARTMENT USE ONLY p Application Accepted by VDate ��+ L�—D� Area � Pit or Grout Inspection by Date Final Inspection by Date 'ZZ � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental 144alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. �I INFO p` CASH Jr 3 + EH 13-24 MEV.10!6331 N l