89-1546 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 5 (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.f or welU pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address �� o 0 City4 �A22/'_ Lot Size - PM A Owner's Name I, c)L f J Address {oo l l�[�x 1\C1ll D. (Zg1Q /V Phone Contractor A&ACK L Address .SC*i r1t►1(l�(,�! -sat'L nese 'No P h a n e `G�1e6/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLIT. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial .❑ Open Bottom -E Manteca Dia. of Well Excavation pia. of Well Casing )<Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`I Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I f Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done Type of Pump _ H.P. State Work Done Rr )a ) J,�? Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is - _ available within-200 feet.) i Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms ..{ Character of soil to a depth of 3 feet: SJR Water table depth SEPTIC TANK, ❑ Type/Mfg """ Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size 6 FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'y SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation _ 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, an 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 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 F certifies the following: 1 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 must call for all required inspections. Complete drawing on reverse side. i J Signed X Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date Area V! Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 6tEt_-- j et" rr/hr ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ T,Z4 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED By DATE PERMIT'NO, +.EH1A-211REV.tix51 EH 11-28 Q t t�3Ytfi