89-2008 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT ii 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209 tr,�Azo ' 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. �/ r Job Address et /�* City -f1 IT Ll Lot Size PM Owner's Name / _,f" /�`An ddress Phone �Qf s G G� / � �� Contractor _,,z7 Z- Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/.Private- ❑ Gravel Pack '❑'Tracy 'Type of Casing Specifications 1"1 Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout _ I I.Irrigation ---Approx. Depth l I Eastern ---/ -Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Done_ s Well Destruction ❑w Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION LI DESTRUCTID ,(No septic system permitted if public sewer is dr -available within 200 feet.) Installation will serve: Residence— Commercial_.._ Other Number of living units: INumber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r 3. Distance to nearest: (.NWell Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: "- Well Foundation Properly Line SEEPAGE PITS I I Depth { Size Number r SUMPS f ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1 .O 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-"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 Californ' The applicant mu call fora))/Q e¢yf a drawing on reverse side. 1 SignedX Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 Date ea Pit or Grout Inspection b ADate Final Inspection by E /`�J Data' �T' v Additional Comments: ❑ Stk 466-6781 C}'Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE CK 1 INFO AMOUNT DUE AMOUNT REMITTED �CASH RECEIVED BY /DATE PERMIVNO. +.EH14-24 IpEV.r/N 5) s' EH 14-2a :. �•I � c;�