89-1295 - 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 t 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. t Job Address 3#0l Cit Lot Sizel�'k`_X 5110 PM 47 OF Owner's Name 444 Address Phone Contractor ' &z74Address '�ly� t License No. �82� Phone TYPE OF WELL/PUMP: NEWWELL ❑'- —- WEL:t REPLACEMENT-❑—T---:=.-•-DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP L FLD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST tON SPECIFICATIONS ❑ Industrial Cl Open Bottom LJ,Manteca of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ©,Tracy Type of Casing Specifications r• FI Public ❑ Other ❑ D Depth of Grout Seat Type of Grout - i I Irrigation Approx. Depth I`Eastern Surface Seat Installed by S Repair Work Done ❑ Type of Pum H.P. State Work Done Well Destruction ❑ Well - in Sealing Material Itop 50') epth Filler Material (Below 50') TYPE OF SEPTIC WO K: NEW INSTALLATION ('I REPAIRlADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) 0 .` Installation will serve: Residence A Commercial_ Other Number of living units: Number of b Brooms - � f Character of soil to a depth of 3 feet: _ /e� _ Water table depth a SEPTIC TANK IJType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of.Disposal Distance to nearest: Well Foundation Property Line s r LEACHING LINE No. & Length of tines Total length/size O FILTER BED"' ❑ Distance to nearest: Well Foundation _ Property Line .` SEEPAGE PITS Depth AZlr44?tSize ,. N ,.,� Ae _ Number SUMPS L3 Distance to nearest: Well_ Foundation Property Line 3I I DISPOSAL PONDS ❑ s l 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 r rules and regulations of the San Joaquin Local Health DiWict. Hbme'owner or licensed agent's signature certifies the following: "I certify_that_in.the pe.gormance;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.".'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." The applicant must cal for all required i pections.+Complete drawing on reverse side. n -Oar r Signed X Title: u Date: Cv `1f IV FOR DEPARTMENT USE.ONLY -� I Application Accepted by Dace Area 12. r Pitr Grout Inspection by Date ��[ Finaf_lnspection.by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.'O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED IGASH RECEIVED BY DATE PERMIT NO. +.EH 13-24 IREV.1 i 8 5i EH 14-28 1 rI T4 s n