89-2879 - Laserfiche WebLink

Home Browse Search

;k s. n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT NOV Z 7 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRONMENTA � ' Telephone (209) 466-6781 �Q LIi PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �R � /SERVICES (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City d Lot Size PM Owner's Name��a AJ Lh E_5U ress 240 C_. `-? Phone Contractor {.l1 Address .G11� License No. �O o Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION RQ?1�e11 SYSTEM 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 /Aomestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications, FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout_ J I I Irrigation Approx. Depth �l I Eastern Surface Seal Installed by _ Repair Work Dane ❑ Type of Pump H.P. Stat Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) 14 LStub Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION,[,,I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve:—Residence_--Commercial_ Other Number of living units: ;.Number of bedrooms, Character of soil toa depth of-3-feet: '` - - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT.PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number r SUMPS L1 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 Heafth 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 fqmpansation laws of California." Contractor's hiring or sub-contracting signature certifies wing: "4 certify that in the performance of the work for ch this permit is issued,l shall employ persons subject to workman's compensa- tion la sof Ca ornia." The a licant st c f r c ions. Complete drawin on a se Side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Applicati Accepted by � /rf/ �r..�� Daal Area � i Pit or Grout Inspection by Date Final Inspection by Dat4s�� 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, Silk., CA 95201 ?FEEO AMOUNT DUE AMOUNT RETT MIED C K RECEIVED BY DATE PERMIT'NO. r.EH 13-24(REV.I/851 EH 14-2$ r