83-94 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT` 1601 E. HAZELTON AVE.; STOCKTON, CA PERMIT NO., Telephone (209) 466-6781 DATE I55UED 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 workherein 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 an e I tions of the San Joaqu.JA Local,Health District. Job Address Subdivision Name F Owner's Name Address -vyt�_1 _ Phone Contractor's Name License No. �'� [/G•Z f _ Phone ' J! ZVI TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 'SYSTEM REPAIR ❑ OTHER [ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION b AGRICULTURE WELL OTHER WELL PITS/SUMPS "�f INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS , Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing 71 Irrigation Approx. ❑ Eastern Depth _ _Specifications , ❑Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout 7[Other Surface Seal—Installed b Repair Work Done ❑ Type of Pump �� H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is p� ; available within 200 feet.) Installation will serve: Residence _ Commercial _ Other a Number of living units: Number of bedrooms Lot-size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKS ❑ Type/Mfg Capacity + No. Compartments _ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method.of Disposal Distance to nearest: Well . Foundation Property Line LEACHING LINE U No. & Length of lines # Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line f 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_perforniance of the work for'Which..this permit is issued, I shall not employ,any.person.in -such manner-as-to become subject`to workman§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 applica m st call or aJ4 re iris actions. Complete drawin on side. .. / Signed X Title: _ /� �i@1 Date: R DE_PARTMENT USE ONLY 7 ApftTication_Accepted'-iy Z41-6= _ Area b ' _ / - �❑ Stk 466-6781 Additional Comments: 1 J ❑ Lodi - '369-362.1 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by _ Date- ❑ Tracy 835-6385 Applicant, Return all copies to: Environmen ealth Permit/Services 1601 E. Hazelton., P.O. Box 2009, Stk., CA 95201 FEE BASE JMOUNT 'DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO t a EH 13-24 REV. 10/82 10/82 540 14-26