84-361 - Laserfiche WebLink

Home Browse Search

bU• UQ �SX• ! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E ; 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �_ R: ' - A (Complete in Triplicate) Application is hereby made to thF 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 0\1 Local Health District. Job Address City Lot Size PM - �IL�D� Owner's Name � s Address ti- �� T� K �TOr'�, ' Phone �� , � 2�lC Qu�rlS r ti Contractor's Name �Va :i License No. Ur 'l3 b 1 ` Phone TYPE OF WELL/PUMP: �;I NEW WELL ❑ WELL REPLACEMENT-❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 000en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ /PPrivate ❑ Grhvel Pack ❑ Tracy Type e of Casing g Specifications � w ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑�lrrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by E Repair Work Done ❑ Type'of Pump H.P. State Work Done Well Destruction Well Diameter _�� Sealing Material /top 50'1 ! Dept14 Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EJREPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is 11 available within 200 feet.) Installation will serve: Reside I ce_ Commercial, Other Number of living units: Number of bedrooms Character of soil to a depth &3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. Ll l – , Method of Disposal Distance to nearest: Well Foundation Property Line -� _ , LEACHING LINE ❑ Noh & Length of lines Total length/sizrty Le- FILTER BED ❑ Distance to nearest: Well Foundation Propeine SEEPAGE PITS ❑ Depth Size Number 1'. SUMPS ❑ Distance to nearest: WellFoundation Property Line DISPOSAL PONDS Ll 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 M 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 Californ' ." This applica mus II for all req red inspections. Complete drawing on reverse Bide. ,, ! i Signed Jb Title: V1Y •+ `Y - �' Date: i FOR DEPARTMENT USE ONLY f Application Accepted by DateArea Z Pit r Grout Inspection by II Date Final Inspection by — CL24 Date S� I Additions! 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 y FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. CASH l i(. INFO ,I 03 au 3 ` 3��(� ��- �! + EH 13-24(REV. 10!83) r „'� �H 1428 i '1428 i Ill ,F