89-1847 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZELTON AVE., STOCKTON, CA k Telephone (209) 466-6781 a PERMIT EXPIRES YYEAR FROM DATE ISSUED q (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 Joaquir' 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 ' S E D�, b-� city S+ Lot Size PM .I! Owner's Name F L Address Phone , ++�M [� GL e License No. f Contractor �+ ��5��—Address �� Phone TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENTCJ t DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTFIER�0-.- DISTANCE TO NEAREST: SEPTIC: ANK SEWER LINES Z DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLL/ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSThiUCTION SPECIFICATIONS ❑ Industrial ❑ Oper-�ottomq—E-Manteca--0ia.;6f Well Excavation `- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public F1Other' 171Delta -,,/Depth of Grdut Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H `. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth /Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW IN I.I/REPAIR/ADDITION STRUCTION I I (No septic system permitted if public sewer is J' available within 200 feet) Installation will serve: Residencel Number of living units: Number of,bedrooms /. Character of soil to a depth of 3 feet: ��„ t -1 �� - Water table depth SEPTIC TANK ❑ Type,/!Mfg` Capacity No.-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dista ce to nearest: ^ `Well Foundation 411 Property Line A9 LEACHING LINE L'�}� .. &I Length of lines Total length/size i FILTER BED ❑ Distance to-near C Well Foundation Property Line SEEPAGE PITS E I Depth Size Number SUMPS Ll Distance to nearest: Well '� Fourid'ation Property Line DISPOSAL PONDS ❑ IN 4 I hereby certify that I have prepared this application arid that the work will be done in accordance with San Joaquin county ordinances, state laws, and Y h rules and;regulations,of.,the San-Joaquin_Local-Healthi District. ti r r 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,1 shall employ persons subject to workman's compensa- tio la f Califorrli 'Ip The applica Chl�dallfoall i ns. to drawing on reverse sidSigned I Title: Date: r 0014R DEPARTMENT USE ONLY Application Accepted by Date Area -�_Pit or Grout Inspection by I Da a Final Inspection by ro 6, / Date i r Additional Comments: ❑ Stk 466-6781 ❑ 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-211REV. EH 10-26 d d