89-633 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r 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 j 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. �j �( Job Address L-sd !/`�r City Lot Size/` �O0 PM x Owner's Name 1 ` VA) x• r Address ` S/ ` C=�!t 6�m Phone ''� �• �[ Contractor 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 L` ._ FOUNDATION AGRICULTURE WELL OTHER WEL " PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other L] Delta Depth of Grout Seal 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 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:-..Residence Commercial_ Other Number of living units: Number of•bedrooms Character of soil to a deptW3f'3`�eei� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal � Distance to nearest: Well i'Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line i \ SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well f=oundation Property Line DISPOSAL PONDS L1 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 r� rules and regulations of the San Joaquin Local Health DiMrict. 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 California." The applicant t call for all required inspections. Complete drawing on reverse si Signed X I Title: + Date: � FOR DEPARTMENT USE ONLY Application Accepted by Date3/. Area OKI Pit or Grout Inspection by Date Final Inspection by Date � 7 Additional Comments: /;7/7 ,4ZI LJ Stk 466-6781 bLodik'369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 1 /f�, / +.EH13-241REV.iin5) 35'u(J 35, oa I0f4� EH 14-26