89-2453 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 OCT O 2 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} ENVIRONMENTAL HEALTH PEf�M1T 1S �1,,�+� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ae�cYhiEff- hIS 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 U City � r Y Lot Size PM Owner's Name klmdress + + ' Y� Phone Contractor Adtlress_0l � License No.AW _bPhone <51 az/ 10 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J0go�,L �p SYSTEM REPAIR ❑ OTHER L1w. E ,v . DISTANCE TO NEAREST: SEPTIC TANK INES _ DISPOSAL FLD. PROP. LINE FO"UNDA"TION--- - 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i l Specifications I 1 Public ❑ Other F Delta Depth of Grout Seal E r Type of Grout I Irrigation —L-Approx. Depetth, �.I,I Eastern �urface Seal Installed by r _ Repair Work Done L3 Type of Pump �_ H.P. State Work Done 1P Well Destruction LlWe1i Diameter .2 Sealing Material (top 50') t [ , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is ^� available within 200 feet.) (/J installation will serve: Residence_ Commercial_ Other v! Number of living units: hh Number of bedrooms Character of soil to a depth tilof 3 feet: Water-table depth SEPTIC TANK ❑ I�Type/Mfg Capacity I No. Compartments r` ) PKG. TREATMENT PLT- ❑ Method of Disposal I /Distance to nearest: Well Foundation Property LineOh LEACHING LINE ❑ rNo. & Length of lines Total length/size �C FILTER BED ❑ ':Distance to nearest; Well r Foundation i Property Line SEEPAGE PITS II JDistance Depth SizeNumber ❑.SUMPS .": .to nearest: ... Well }- yFoundation� Property Line-_.- _ y ` �,.— DISPOSAL PONDS ❑�� ti,-` . 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 Diltrict. , 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 whi this permit is issued-,,I,shall employ persons subject to workman's compensa- tion laws o rnia." 71 The app/- ant mu r all r ired ' tions. Complete drawing n r ase side. Signed LJ I Title: ' Date: FOR DEPARTMENT USE ONLY Applicatio/Ac.p Date \b Area I Pit or Grout inspection by ') Date Final Inspection by Date 1q Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 11 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE pPPERM`IT'NO. +-EH 13-24(REV.i/)15) G.✓ V EH 14-26 h II ,