89-1383 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 37. / 1601 E. HAZETON AVE., STOCKTON, CA 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4)c-r Job Address ` +y�� City Lot Size PM Owner's Name Y 1�/Y-� �!7' Address Phone T r SAddress� 7`��k' License No. K��J Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION 4'RPpu11'_Q SYSTEM REPAIR' OTHER O 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 ❑ Domestic I Private ❑ Gravel Pack [I Tracy Type of Casing Specifications r'] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout__ }(Irrigation —Approx. Depth l ] Eastern ce Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work DoneF/11;CT;0 d`;�j�'� _1 Well Destruction ❑ Well Diameter Sealing Material (top 50') s .. + h �Z r� Depth Filler Material (Below 501 61;57� /_�-_ _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRJADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other .n Number of living units: Number of bedrooms J- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 7, f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDi ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 a rule`s lind`regulations of the San Joaquin Local Health District. Homo owner�o�'li��itise3 agenjs-signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ.any pprsllYj..9,66 rnannet_as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin4: "I Cortify'tTt t the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lau/s'of California.°' 1 The app)cant�rnvst I'll grI II Ireq Ctions. Complete drawing on reverse side. Signed X '//f� � _Title: AnW1, Date: ' F EPARTMENT USE ONLY j Application Accepted by Date �L_/V� AreaIV Pit or GroutYnspectionn by Dater _ —„Final Inspection by _ _ Date SIl 0-4 Additional Comments: — a•^ - -� —� LIStk 466-6781 171 Lodi 369-3621 `0 Mac rite823--7104` �' \EITracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTrrDyyU''E,, AMOUNT REMITTED CK 11 CASH RECEIVED BY DATEPERMIT'NO. Vk + EH 1324 IREV.t/H b7 �' W /_ J(,-1y_g7 S--1353 EH 14-28 &