89-624 - Laserfiche WebLink

Home Browse Search

�= APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 1 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED R (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hpteih.de cert c 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) AO—We p.� Job Address 210 — s�/—�v — City 0V Lot Size PM, Owner's Name Add es �� (y • ' r �- Phone 371161 ,h N $ Address Phone �l Contractor �CQ ! License No. TYPE OF WELL/PUMP: NEW WELL DWELL REPLACEMENT 17 DESTRUCTION [5PUMP INSTALLATION)k 7 Je;Cft SfH%YSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing = Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation —..,Approx. Depth. L.I.Eastern_: rqa a Seal Installed-by Repair Work Done E3 Type of Pump H,P. ��— — State Work Done Well Destruction ❑ Well Diameter _Sealing Material itop 50'► Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available-within-200-feet:i - — --- - W Installation will serve: Residence_. Commercial_ Other Number of living units: Number of bedrooms e Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg "¢ Capacity jf , No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, 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 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: "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 m II wired i Complete drawing on rave side. Signed X Title: 0� Date: FORD ART NT USE ONLY � . Application Accepted by Date v ' Area y Pit or Grout Inspection by Date Final Inspection by Date'T r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca— d3l-71040 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. P INFO ! CASH i.EH 13-24 1REV.1/H 57 EH 14-28 `-ice