89-2046 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' } SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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. IB62 for wo/pump and the Rules and Regulations of the San Joaquin Local Health District. City V t6<10 Lot Size PM I4 Jab Address G Q��_ Phone _71fQ Address Owner's Name .9 Contractor I! SLC. Address r License No-��Phone tj TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14 /➢ �, Dia. of Well Casing III 11 Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` Specifications I Gavel Pack ❑ Tracy Type of Casing Domestic/Private Delta Depth of Grout Seal Type of Grout ! F1 Public Cl Other ... I I Irrigation — Approx. Depth l i Eastern SUTface Seal Installed by Repair Work Done Type of Pump H.P. /--� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Iis pepth p Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION I 1 DESTRUCTION I i alvailablelwihin 200 feetc system tjed if p k ti Installation will serve: Residence� Commercial� Other Number of living units: Number of bedrooms Water table depth j Character of soil to a depth of 3 feet: No:Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ , Distance to nearest: Well Foundation Property Line s I LEACHING LINE ❑ No. & Length of lines ff Total length/size— EJ r Property Line FILTER BED Distance to nearest: well Foundation r SEEPAGE PITS { I 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 ormance of the work for which this permit is issued, l shall not that in the perf 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 st call quired inspections. Complete drawingon re erse side. Title: ! I Date: Signed X f , , FOR DEPARTMENT SE ONLY Data Area Application Acce ted by 1 Pit or Grout inspection by �Date Final Inspection by Date Additional Comments: ✓� / l' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 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 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO +.CH 13.24{REV,1/fly] EH 14-2e r _ 7