89-1787 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT w, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I 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 N.59 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. ,VA 1✓O N� City TLot Size PM Job Address .- �� Ali 9 _ i Phone I Owner's Name T'nTi� T1Tti;�i�TRTI T{ Address jSr �dp.*s.fy-14oa DEITIIS 1,L5'SliJt�n C0112vACTURs C 1 141— License No. '�77'85—Phone'3 �t Contractor - Address P TYPE OF W L! UMP- NEW WE Lb- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION;-.gL:. SYSTEM REPAIR ❑ OTHER ❑ "DISTANCE TO NEAREST: SEPTIC TANK a I • SEWER LINES DISPOSAL FLD. 'PROP. LINE —1E) + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE CATIONS 6 ❑ Industrial EJ Open Bottom ❑ Man teca Dia. of Well Excavation Dia- of Well Casing ` .. Type of Casing_ rr Specifications .D Domestic/Private ti�CL-r�ravel Pa1. 1ck.=+Yi� ❑1Tracy.. l"1 Public f7 Other- �- n Delta *Depth of Grout Seal Type of Grout ?? =— �7�- I.!-krigStiori — �.:Approx. Depth I 1 Eastern Surf Seal Instal by, u[] H P State Work Done si 1 'tel Repair Work Done 0 Type of Pump � Well D'esuuct_ion Ll Wel! Diameter Sealing Material (top 50') { 1 ) ^; Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRIADDITION l I DESTRUCTION I 1 al o septic ssystem 200 f�eetlt'] � public sewer is installation will serve: Residence_ Commercial— Other . Number of living units: �' Number of bedrooms .�� Water table depth Character of soil to a,depth of-3feet: h 'SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ke'l4 9 PKG:•TREATMENT PLT. ❑ Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE L! No.No. & Length of lines Total length/size FILTER BED O E Distance to nearest: Well Foundation Property Line �` F SEEPAGE PITS l 1 Depth Size Number l SUMPS L! Distance'to nearest: Wel! Foundation Property Line f r DISPOSAL PONDS ❑ a that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and I 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 shat! not. of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compensation laws f the work for which this permit is issued,I shall employ persons subject to workman's compens�' certifies the following:: "t certify that in the performance o tion laws of California." { The applicant mus all or all required inspections. Complete drawing on reverse side. �,�� Title: Date: 7-26 9 Signed X . FOR DEPARTMENT USE ONLY iAA Date Area Application Accepted by q Pit or Grout Inspection b Date Final Inspection by _Date 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 FEE CK RECEIVED BY DATE PERMIT'NO: INFO AMOUNT DUE AMOUNT REMITTED � H /7Z r.EH 13-24IflfV.1/951 .3U G— f! EH 14-2B