84-562 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 A7 fi� City Lot Size 4 X /9 PM S Owner's Name,N-4/6.05 4!Address Phone 4X- eA Contractor's Name f P./�'l !� 9 trf�„� License No. 1`� 'rya Phone « d7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5 . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLL' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ,'Well Excavation Dia. of Well Casing '11-Domestic/Private❑-Gravel'Pack""----'13;Tr y"—'"'"""'"'""'"Tye'of'Casing Spec ifications [IPublic ❑ Other w;k'+t'❑,Delta Depth of Grout Seal Type of Grout C f E] Irrigation _._ Approx. Depth ❑ Eastern- Surface Seal Installed byw- ;Repair Work Done ❑ Type of Pump . State Work Done .. Well Destruction ❑ Wel] Diameter ]Sealing Material (top 50') Depth r 1 '* Filler Material (Below 50') 46� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑—REPAIR/ADDITION DESTRUCTION Ll (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_! Commercial ~_ Other , Number of living units: Z Number of bedrooms 13 Character of soil to a depth of 3 feet: C-z J9 V ! _Water table depth .0 I SEPTIC TAS"�TypelMfg - `"�c3� `Capacity yb No. Compartments IPKG. TREATMENT PLT. ❑ Method of Disposal; Distance to nearest: Well Foundation ! b Property Line f = r LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line { r .SEEPAGE PITS ❑ Depth I 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 n countyordinances state laws, and rules and IIregulations of•the.San Joaquin' Local Health District. 1 S 9 q c .Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall nota employ any person in such;manner as toibecome subject to workman's 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 compensa tion laws of California." I! The applicant must call for all required inspections. Complete drawing on reverse de. 'Signed Title: Date: 4F -FOR-DEPART ENT-USE-ONLY Application b Accepted r P Y Area Date LJ Pit or Grout Inspection by Date Final Inspection by__v,VI Date Y-01-710 Additional Comments: I-- + '* -Z�L N�- `'C - !.. ❑ 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 FEEINFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH13-24(REV.1018331 l J �o EH 1428 / 73