89-888 - Laserfiche WebLink

Home Browse Search

x J ji APPLICATION FOR PERMIT SAN JOAQUIN• LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA t i Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED G i (Complete in Triplicate) s 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. X Job Address � � C �V�� w� Cit » Lot Size_'_�, \ � PM xOwner's Name Address AddressPhone 4 u Contractor Address �... N License No. µ Phone TYPE OF WELL/PUMP:: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR_ _❑ _ _OTHER ❑- :-r- _DI STANCE-TO•NEAR EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS _ CNTENDED USE TYPE OF WELL PROBLEM AREA-- CONSTRUCTION SPECIFICATIONS 1 i r ❑ industrial I ❑ Open Bottom ❑ Manteca Dib. of Well Excavation Dia. of Well Casing s El Domestic/Private ] El Gravel Pack El Tracy _ Type of Casing Specifications M Public I i (l Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation j Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump---- -mH.P., �� State Work Done_ Well Destruction ! ❑ Well Diameter Sealing Material (top 50') '$ s j� Depth ° Filler'Material.(Below 501 TYPE OF SEPTICI WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l ] DESTRUCTION (No septic system permitted if public sewer is jl a i available within 200 feet.) Installation will'serve: Residence_ Commercial_ Other f Number of living units Number of bedrooms Character of soil to a depth of 3 feet: 'Water table depth SEPTIC TANK i� j ❑ Type/Mfg, Capacity �No. Compartmentsf "PKG. TREATMENT PLT-.I❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE }F❑ NO'. & Length of lines Total length/`size FILTER BED s ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I' $;l j a Depth Size Number _- -- . __.-_. _ -- - _-_ SUMPS I ( Ll Distance to nearest: Well Foundation_ Property Line 9 c DISPOSAL PONDS ll ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of"the San Joaquin Local Wealth Di'strict.� M -•�^-- •-- --- -< Home owner or kensed'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 manlier 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."' r The applicant m t I jore4 required inspections. Complete drawing on revere si e. Signed X �.. .. .«Title Date: r i Q , FOR DEPARTMEN USE ONLY � Application Accepted by - ��(L� Date _ r? Area a I j Pit or Grout Inspection by Date Final Insia.ection by Date t Additional Comments: i ❑ Stk 466-678111 ❑ Lodi 369-3621 O Manteca 823-h04 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ii FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. n (3 EH 3-24 t + EH 14-28 IREV.1/H 5) `- u, l s' -