89-1402 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 1YEAR 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 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. Pp On is r Job Address S / j City Lot Size PM Owner's Name Address_25-39'f" A/ F-j.I Phone-�,F_ Contractor AddressJ_6" , eek, TYPE OF WELL/PUMP: License No,?9_9 3,p3 phone NEW WELL LJ REPLACEMENT ❑ PUMP INSTALLATION ❑ DESTRUCTION DISTANCE TO NEAREST: SEPTIC iC TANK SYSTEM REPAIR El LINES DISPOSAL FLD. PAOP LiNE 4' FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Greve) Pack Dia. of Well Casing l O Tracy Type of Casing i"3 Public C1 Other Specifications I R Delta Depth of Grout Seal , I Irrigation —_IApprox. Depth I I Eastern Type of Grout Repair Work Done ❑ T Surface Seal installed by ype of Pump H P W Well Destruction ❑ Well 8iameter ~- State Work Done_ i Sealing Material (top 50') \ Dept Filler Filler Material (Below 50') V� TYPE OF SEPTIC WORK: NEWiINSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I (No septic syste �4 ,iii _ permitted if public sewer is Installation will serve: ResidenceCommercial available within 200 feet.) Other " ' Number of living units: Number of bedrooms ~~ ` Character of soil to a depth of 3 feet: !'W SEPTIC TANK 'l Water table depth ❑ Type/Mfg N G. Capacity�� PKTREATMENT PLT. ❑ I�I No. Compartments Distance to nearest: Wel! Method of Disposal iii Foundation Property Line LEACHING LINE ❑ No.!R& Length of lines #� i FILTER BED LJDistance to nearest: Well Total length/size _ ion Property Line SEEPAGE PITS =i-I" 'Dep'ih w ze Number SUMPS L� Distance to neareSinearest Well �` DISPOSAL PONDS ❑ I� Foundation Property Line l 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 Di§trict. 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 f employ any person in such manner j'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 compansa- tion laws of California." �� The apil must call for all r u.lred ins L pection . Complete drawing on reverse side. Y,=. Signed X � Title: i Dater FOR DEPARTMENT USE ONLY Application Accepted by I� U� r Date� ~ lb^' I`. Area Pit or Grout inspection by I Date��— Final Inspection by�� r Additional Comments: Ite ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 y Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton 835-6385 3 e., P O. Box 2009, Silk., CA 95201 it �. 4 FEE INFO AMOUNT Ol.]E AMOUNT REMITTED CK v ASH RECEIVED BY DATE pERM1T'NO. 1. EH 13-24(REV.i i n 51 �;1 EH f/4-281 �� i!I �