84-319 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q H 3 Telephone (209) 466-6781 DATE ISSUED 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 5 Joaquin cal ealth District. Job Address (! 1 Subdivision Name *: Owner's Name ddress Phone ------------ Contractor's Name License No. Phone p TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS p INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + IJ Industrial U Open Bottom Fj Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public [10ther Delta Type of Casing [j Irrigation Approx. Eastern Specifications F—ICathadic Protection Depth Depth of Grout Seal Geophysical Type of Grout 0ther Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well-Diameter Sealing Material (top 50'}. ,._ Depth Filler Material _(Below , TYPE OF SEPTIC WORK: NEW Ii.NSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y- Commercial Other Number of living units: Number of-bedrooms Lot size i Water table depth r Character of soil to a depth of 3 feet: SEPTIC TANK E] Type/Mfg ^-'o r Capacity No. Compartments � PKG.I TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM f7 Distance to nearest: Well } Foundation. Property Line DESTRUCTION p ,� LEACHING LINE � No. & Length of lines Total Iength/size ` FILTER BED Distance to nearest: Well . Foundation Property Line SEEPAGE PITS Depth mak- Size Number _ 14 SUMPS IJ Distance to nearest: Well /,Zo P, Foundation Property Line DISPOSAL PONDS ED I I he 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"Ar,-kman� 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 compensation laws of California." The applicant m c for all required inspect ns. Complete drag on r erre e. Signed X f Title: Date: F DEPA MENTU E ON Y tk 466-6781 { } Application Accepted byffl/ Area odi 369-3621 Additional Comments: i Pit or Grout Inspection Date U Manteca 823-7104 Final Inspection by Date Tracy 635-6385 / L I Applicant - Return all copies o. Envir mental ealth Permit/Services 160 zel on'Rve., P.O, Box 2009, Stk., CA 95201 t PP FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �DATE C'PERMIT NO.. INFO 21-f--3 r 10/82 500 EH 13-24 REV. 10/62 14-26