89-284 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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.p// 1 ' -7 4Ll Ampo Jab Address d-`7 �, � 2 Cit Lot SizeX , PM Owner's Name Address f� t /([� /�,� l J� 11 Phone Contract Address c? ,License No. z Phone VA TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 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 El Domestic/Private C) Gravel Pack ❑ Tracy Type of Casing I 'A Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.f P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material it6p 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION l IDESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation wiiii serve: Residence V' Commercial_ Other Number of living units: Number of a rooms ' _ 7 Character of soil to a depth of 3 feeWater table depth SEPTIC TANK Type/Mfg t'F Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 � s ti .`+ Method of Disposal Distance to nearest! Well ,Foundation A Property Line .2 LEACHING LINE No. & Length of lines j �Y l Total length/size K FILTER BED ❑ Distance to nearest: Well F=oundation l Property Line SEEPAGE PITS Depth Size ` �� Number r SUMPS ( _ Distance to,nearest: Well ` yFoundation � Property Line j51- DISPOSAL PONDS ❑ 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, an rules and regulations of the San Joaquin Local Health District. �• Home owner or licensed agent's-signature certifies the-following:"') 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."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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m s�Ifk ned i spections. Complete drawing on reverse si {� Signed XTitle: Ltr Date: FO DEPARTMENT USE ONLY Application Accepted by ` _ Date Area '12 or Grout Inspection by ..,Data Final--inspection bye Date 2_-21-- x Additional Comments: �`' r ❑ 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 i FEE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIT-NO. INFO ��D Q *.EH 174-28 O3-211REY.tin51 EN 770. �¢ �� y�g