89-3002 - Laserfiche WebLink

Home Browse Search

F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 1 i 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 !//; S G City Lot Size PM , Owner's iName Address j Q j Phone Contractl'orPs 21--5;r W57 Address © w del/A<OW License No!7 57y3'yT Phonewiw 0;7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ /x i PUMP INSTALLATIO_N_❑� F SYSTEM REPAIR C1 OTHER p 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 "' t O Industrial ❑ Open Bottom CI Manteca JDia. of Well Excavation Dia. of Well Casing r El Domestic/Private ❑ Gravel Pack El-Tracy•—„'✓" Type of Casing ! Specifications f'7 Public (7 Other ❑ Delta Depth of Grout Seal r Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. _ _ _ _ State Work Done_ 1 Well Destruction ❑ Welt Diameter Sealing Material (top 50'f Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.' Installation will serve: Residence Commercial Other 4— Number of living units: Number of-bedrooms v,} Character of soil to a depth of 3,feet: ater fable depth �O r SEPTIC TANK X, e/Mf Yp g Capacity No. Com artments 2� G �.. p PKG. TREATMENT PLT. ❑ , r Method of Disposal - -Distanc6,to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED r ❑�,bistance to nearest: Well Foundation Property Line SEEPAGE PITS l I DepthSizeZ Number + t SUMPS 0—Distance to nearest: Well Foundation L. Property Line ' 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, and rules and regulations of the San Joaquin Local Health District. 1 i Home owner or licensed agerit'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 persomin.such-manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow' : "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 Cali ria." T� - The applica call f all r ins t" Complete drawing on revers ides r. Signed X f / Title:��, �� Date: � / -3 r ly~ ( FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by DaterFI- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-241REV.tin 51 /� i -EH 14-26 V