84-70 - Laserfiche WebLink

Home Browse Search

Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 2,2-4_ 0 c f 0—5,6 O E 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 I 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 Loc I Health District. Od 040 `SCA Ci Lot Size �- �PM Job Address //'',,,,,,,, f�f�-+L. Owner's Name ��i . 1 ��as Phone ` 1 Contractor's Name License No.! 13 A ' Phone 9 g-o-Y TYPE OF WELL/PUMP: ' tNEW�WELL.❑f 4 f WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION T❑�J. I {SYSTEM REPAIR 1:1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL___L_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �T Industrial F-1Open Bottom Manteca r Dia. of WeII Excavation Dia- of Well Casing II a I. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy SType of Casing ^ I Specifications ; ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — { ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by I � Repair Work Done ❑ Type of Pump i'P. State Work Done r Well Destruction 1-1WellDiameter Sealing Material (top 50') Depth Filler Material (Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION ❑^REPAIR/ADDITION CJ DESTRUCTION IJ (No septic system permitted if public sewer is v ,4:4available within 200 feet.) t Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. nj Method of Disposal Distance to nearest: Well Foundation Property tine LEACHING LINE ❑ No. & Length of lines • Total length/size FILTER BED eE] Distance to nearest: Well Foundation Property Line SEEPAGE PITS ElDepth Size Number r !' 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 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." The applicant must call for all reAulred inspections. Complete drawing on reverse side.+ ' f SignedN\ACAAA- Title: Date: FOR DEPARTME . USE ONLY Application Accepted by Date Area 13 Pit or Grout Inspection by Date Final Inspection by .. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ZWanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO rh, CASH ^�'] Q'a.t� + EH 1324(REV.10!93) O V �7 �� - Ir�+f r• 1 ��—� o rw 1i7H