89-782 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. �I SII Job Address III �- City ,A ttn Lot Size y Q G PM F ��/y D A 2 7 ka V T 1 Phone _317� Address Owner's Name -�"W _J1�$I k Contractor Address pt o ;f] License No. U Phone 162 If TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION) SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK Ld _ SEWER LINES DISPOSAL FLD. PROP. LINE ' ! __' II r FOUNDA I ION_ _AGRICULTURE WELL,-__ HER WELL PITS/SUMPS f' INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ;� rDia. of Well Casing ! 111 Industrial ~"�i;Open Bottom 11 Manteca Dia. of Well Excavation i 4 � Specifications Domestic/Private ❑"`Gravel Pack ❑ Tracy Type of Casing a �- f1 Public F116ther LI Delta Depth of Gr6 t Seal Type o roueC : t. 11 — I I Irrigation -Approx. Depth 1 1 Eastern Surface Seai installed'by " h - Y Repair Work Dane ❑ ! li Type of Pump H•P State Work Done C Well Destruction ❑ Well Diameter Sealing Material (top 50') w Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: I-Residence— Commercial— Other t �N � Number of living units: Number of bedrooms ;� - Character of soil to a depth of 3 feet:` Water table depth ' SEPTIC TANK J❑, Type/Mfg Capacity t. No. Compartments PKG. TREATMENT PLT:❑ /'` ;. Method of Disposal / Distance to nearest: Well r-Foundation! . Property Line LEACHING LINE a ❑ No. & Length of lines . Total length/size FILTER BED ❑. 'Distance to nearest: Well Foundation 4 Property Line ; I SEEPAGE PITS 1 1', Depth Size _Number SUMPS / L Cl Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ V \1 I hereby certify that.•I have prepared this application and that tlre,work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies the following: 'I certify-that in the performanc of the.work for which this permit is issued, I shall not t 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 ceri'ify that in the performance of the work for which this parmit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." s'v The applicant must call for allre aired inspections. Complete drawing on reverse side. x/Eq Signed 1 ,� ra� LI — Title: FOR DEPARTMENT USE ONLY l Area i � O Application Accepted by Date �` � Pit of taut �+spection by e Date e Final Inspection by r i Date _ Additional Comments: t ) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835_&V5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 1'AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO tv EH 13-24(REV.5/H 5) �3Z-1 Ed EH 14-28 - i