89-1737 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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. Job Address City Lot Size PM Owner's Name �Ae�a-A.4-sVL^ Address .�.enlL- .C.1 Phone Contracts Addres C icense No. / Phane r� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom 5 Manteca Dia. of Well Excavation Dia. of Well Casing Vpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depthu�I I Eastern 1� Surface Seal Installed by Repair Work DoneType of Pump..�fs. H.P. 1_/fir State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material {Below W'I _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I (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 depth of 3 feet: Water table qeg — SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ 41�,IDiposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Prop9" tl`t MIEALTH SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 n�l 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 must all for i11 r quired inspections. Complete drawing on reverse side. Signe _. Title: • Date: `� r FOff,XEPARTMENT USE ONLY Application Accepted by Date ' Area Pit or Grout Inspection by DateZ4 Final Inspection by Date k�6- � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L1 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 FEE INFO AMOUNT DUE AMOUNT REMITTEDCK CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.i/x 5) S`vo k 2-:;LL(—,FJ y-S �7�G-J7F7 EH 11-29 �