84-656 - Laserfiche WebLink

Home Browse Search

�w P .� APPLICATION'FOR'{PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ■�,re1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 z.;AY 2 5 19 84 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED # (Complete in Triplicate) SAN ,SOA UIi g'L�O(C+'p+` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein A&QdT. . iCdtl 7Pi§ 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. .1 l441 Job Address I "u City Lot Size PM 7�ec Owner's Name '719�1tiP.Q_� (�(/j � Address -7Crr' Phone �/ J p y � Contractor's Name License No. C11 go/J�� Phone TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK AQiQ'+ SEWER LINES DISPOSAL FLD./M i_ PROP. LINE FOUNDATION -' AGRICULTURE WELL OTHER WELL! � PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IX Domestic/Private %Gravel Pack YK Tracy :;Type of Casing ,AI�II-1 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -_ ��?a Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern i.Surface Seal Installed h Repair Work Done ❑ Type of Pump H.P. A State Work Done 5 Well Destruction ❑ Well Diameter Sealing Material (top 501 — Depth Filler Material {Below 50') 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 bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line it SEEPAGE PITS ❑ Depth Size Number SUMPS -O Distance to nearest: -Well----- ;i 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 fbr which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Ii The appli ust call far all re it d inspectio s. Com ete d wing'on ev rse side. Signed �• itis: Date: is y FORDEPARTMENT U5 ONLY Application Accepted by Date S Z��--�i Area O Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 E INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 73-24{REV.10/83) „�t EH 14-28 +a r