84-168 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l 1 • ff J i, PERMIT NO.T` DATE ISSUED 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 a dR uiations of t e San Jcaq in Local health District. Job Address % r Subdivision dyi�viision Na e Owner's Name 1.d ,. � Al7 1 i Address it d 1To11 z 71V Phone Contractor's Name f MdAd ;;r l;_ 14i/X44icense No, 37 10fj y Phone 799— 3-3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE ❑ Industrial Domestic/Private —1) Public Irrigation ❑ Cathodic Protection ❑ Geophysical Other Type of Pump r' H, P. It Well Diameter Sealing Material Depth Filler Material TYPE OF WELL PROBLEM AREA Open Bottom ❑ Manteca ❑ Gravel Pack ❑ Tracy [j Other [] Delta Approx. ❑ Eastern Depth Repair Work Done ❑ Well Destruction 1-1 CONSTRUCTION SPECIFICATIONS Dia, of Well Excavation _ Dia. of Well Casing Type of Casing Specifications Depth of Grout Seal Type of Grout Surface Seal Installed State Work Done (top 50') (Below 50') PROP. LINE PITS/SUMPS TYPE OF SEPTIC WORK: NEW INSTALLATION Ci REPAIR/ADDITION J� (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEMDistance to nearest: Well DESTRUCTION ❑ Other Lot size _ Capacity Capacity Foundation Water table depth No. Compartments _ Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 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 applicamust c for all requir d nspections. Complete draw'jg on r ase si Signed X Title: Date: 2 2 2. 0 EPARTMEN7 ll NLY Application Accepted by �`� Area ❑ Stk 466-6781 / Z. Additional Comments: �odi 369-3621 / Pit or Grout Inspection by 6 Date ❑ Manteca 823-7104 Final Inspection by r Date / ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Valth Permit/Services 1601 E. Hazelto A�V, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE INFO AMOUNT REMITTED 0 R�ECEIVE�D BY DATE PERMIT NO. -F-9 _I EH 13-24 REV. 10/82 (�j f ��j 10/82 500