84-326 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Cc R ! 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 jP- ry PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ; (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wq06147,111e6criAMI 1hCiOftation is made in compliance with San Joaquin County Ordinance No:549 for sewage or No. 1862 for well/pump and the Rules�End&,Fgp:at8f pp r Joaquin Local Health District. Job Address 44}}7 Z r! City' Lot Size PM Owner's Name o-O 2ty �` dd.. Phone Contractor's Name License No. 4 Z-3 7 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Qi SYSTEM REPAIR 2' OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS QrIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' ❑ Irrigation ---Approx. De th ❑ Eastern Surface Seal Installed by Repair Work Done 9� Type of PumpH.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material [top.501 ...,�...�. ,__...-.mow-, x�.__...�- --- • ---�----- - - Depth Filler Material [Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ¢ ! available within 200 feet.! Installation will serve: Residence._ Commercial_rdther 7 t Number of living units: - Number�of bedrooms W W i Character of soil to a depth of 3 feet: 4 i Water table depth SEPTIC TANK ❑ Type/Mfg' -'� R' Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal Distance to nearest: Well Foundation 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 ❑ 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 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 applicant }st II for all r uired inspections. Complete dra wing-OR reverse side. (1 Signed 'title: Date: '3 �� [Jlr 54 FOR DEPARTMENT USE ONLY �/ Application Accepted by v� Date 2 � dK Area Pit or Grout Inspection by Date Final Inspection by-- `F Date Additional Comments: - ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 yf ❑ Tracy 8:35-6385 Applicant- Return all copies to: Environmental Health Permit/Services,,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. +EH 13-24 IREV.10/83} LA S . d 0 EH 14-28