89-1729 - Laserfiche WebLink

Home Browse Search

APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 l0 ""'' City Lot Size PM Owner's Name Address Phone Contractor) � � Address AD SLicense N0P3/?6-)— Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO.N.. Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LQZBomestic!Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications t i ( I Public ❑ Other ❑ Delta ; Depth of.Grout Seal Type of Grout I I Irrigation _.-Approx. Depth t-I'Eastern .X Surface Seal Installed by - Repair Work Done LDType of Pump_— H.P.��y� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') � I Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION (.1 REPAIR/ADDITION I I 'DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other i � r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth thh SEPTIC TANK 0 Type/Mfg Capacity N, W PKG. TREATMENT PLT. ❑ I L14! of Dispos l �e Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' q !989 _ FILTER BED © Distance to nearest: Well Foundation Property Line C� ROr v C1 V SEEPAGE PITS I ) Depth Size s � Number PERMIT/SERVICE SUMPS ❑ Distance to nearest:—+- Well Foundation Property Line DISPOSAL PONDS ❑ i 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, l 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cq for all req 'rad inspections. Complete drawing on reverse side. Signed X '- Tifle: Date: FOR DEPARTMENT USE ONLY �/� Application Accepted by Date Area �7 Pit or Grout Inspection by Date Final Inspection by Date_ / f Additional Comments: z EIStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 © Tracy 835-63135 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. I INFO �,�) CASH p ..EH11241RFV.t/H5f �a- ��tf',-p�'j 001^/7,2 I ''' EH 14-26