84-576 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE..TON AVE., STOCKTON, CA Telephone (209) 466-6781 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 San Joaquin Local Health District. �] ! Job Address D� W, City Lot Size PM * Owner's Name AAWA44 IMM-5 111 Address _r!L/� Phone [o Contractor's Name mMaav License No. Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A --PUMP INSTALL�AyTTIION.��i SYSTEM REPAIR, OTHER El DISTANCE TO NEAREST: SEPTIC TANK ry5 fr SEWER LINES DISPOSAL FLD. l PROP. LiNE N ,-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing - Specifications ❑ Public f❑ Other ❑ Delta Depth of Grout Seal I Type of Grout ❑ Irrigation I—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump�_ H.P. State Work Done' r Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:.NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septfc system p rmitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f i I Number of living units: Number of bedrooms � t. Character of soil to a depth of 3 feet: I Water.table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ .•�' ' t Method of Disposal r Distance to nearest: Well r Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature S 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 applican us call for all required inspections. Complete drawing on reverse side. C f Signed r Title: Date: FOR D ARTMEN USE ONLY Application Accepted by Date �114 y Area � Pit or Grout Inspection by Date Final Inspection by Date L/o — l Additional Comments: ❑ Stk 466-67$1 ❑ Lodi 369-3621 Xmanteca 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 FEE AMOUNT DUE AMOUNTREMITTED RECEIVED BY DATE PERMIVNO. INFO EH 4-28 1 �["` g� +EH 13-24IREV.10193) [ 5 L1.,7 y�/ 1