89-2051 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT g SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applic i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 11362 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. f City Lot Size •, PM l Job Address /�/�) � � /a�• ,�D �T e� I V �Q�/ 0 Address !t✓" ' a (�! Phone Owner's Name ��j �j� Contractor S W��i dfess� 17 _,VLicense No. Phone�..-. _ - --- -_WELL d ---��V1lELLuFiEPLACEMENT� l� _�_�bESTRUCTION ❑� 1 TYPE OF WELL/PUMP: OTHER 1-1PUMPr INSTALLATION SYSTEM REPAIR L] �• SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK 1 " 3 WE ----OTHER-WEL- -PITS�v`LIMPS-_-- ----- _.,,,..__..__......o-.-,�f©H{�f3Ai�iON. AGRIC��T�RE�WEiI � � s E �. INTENDED USE TYPE OF WELL PROBLEM AR A GONSi3UlsTIONSPECIFICAT�IONS Dia of Well Casing 4 Industrial �^ ❑ Open Bottom # ❑ M'3Ytteca�""'terDia-of-WeH-Excavation--w•�-``� / ; Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ T�acy Type of Casing - lielpair PublicLl Other 1-1 Delta Depth of Grout SealType of GroutIrrigationAprox. Depth Eastern Surface Seal Installed by�;- . 4. t �rH p _�Q State Work Done Work Done Type'of P�mp i (Nell Destruction ❑ ��gWtell Diameter � Sealing Material It pI50'1 I JDepth_ 7 \I I Filler Material (Below 50'I f, , tsystem TYPE .OF SEPTIC.WORK: NEW jNSTALLATlt7 I:I REPAIR7ADDITION l I DSTRUC IdN l.aNailabPelw thin 200-feetit�ed if public wer is installation will serve: Residence CommercialOther s 1 ' Number of livirI units: Number of bedroo ms j t, Water table depth I Charact it of soil to a depth of 3 feet: t II t�j p Type/_Mfg, Capacity y 1 No. Compartments 1 ,PTIC TANK J _ i Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE C No. & Length of lines Total lengtIh/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE IPITS I 1 Depth Size Number i I SUMPS ❑ 'Distance to nearest: Well Foundation Property Line I DISPOSAI 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, and rules and �eguladons of the San Joaquin Local Health District. 9--- - �;- e ' Home owner or licensed agent's signature certifies the following: "I certify that in theiperformance of the wak•for which This permit is issued, 1 shall not employ an�r person in such manner n to become subject to workman's compensation laws of•Celifornia." Contractor's hiring o�sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perrktfijiisueclj'i shall amploypersons subject to workman's compensa- tion laws of California. The applicant must all for all quired inspections. Complete drawing on revere Signed X Title: `/ Date: FOR DEPART ENT USE ONLY I Date Area i Application Accepted by r Final Inspection by c Date Pit or Grout inspection by date 4 Additional Comments: L1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C3 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l - i jCCAY'S RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED HINFO ��EH 13-24 IREV. k EH 11-29