89-1821 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601"E. HAZEIL ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s iCornplete 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. two u Rd Job Address ,�} City � T� Lot Size PM Owner's Name /�C" Address Phone f I/19,a Contractor/ ,f'/ f.�n.��_ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION" ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑"Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications_ I F1 Public } n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _."Approx. Depth I i Eastern Surface Seal Installed by Repair Work.Done. " ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') -- Depth Filler Material (Below 501 T TYPE OF SEPTIC WORK: NEW INSTALLATION I'I' REPAIR/ADDITION 5& DESTRUCTION [ (No septic system permitted if public sewer is �[ A available within 200 feet.) Installation will serve: Residence X Commercialcher Number of living units: Number of bedrooms Character of soil to a"depth of 3 feet Water table depth SEPTIC TANK Type/Mfg 4O>,OCICGPC, 10 tL Capacity. No. Compartments 2 PKG. TREATMENT PLT, ❑� Method of Disposal Distance to nearest: Well Foundation Property Line ^� LEACHING LINE r� 9f No. & Length of lines Total length/size A. FILTER-BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS A 1 Depth Pl ti ]? -size A 100 Number . _ SUMPS ; _ Distance to nearest: Weil_140 r•t• Foundation�d�_ Property Line /U 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 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 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 l certifies the fol0wing: "I certify that in the performance of the work for which thisermit is issued, I shall em Id P employ persons subject to workman's compensa tion laws of California." The applicant must call f r all required inspections. Complete drawing on reverse side. n Signed X T ., ,�.�Title: date: ,. �. .FOR EPARTMENT USE ONLY ' , Application Accepted-by //� _ fir Date Area Pit or Grout Inspection byjj Dapte Final Inspection 6 0 ' Date Additional Comments: ' C / /L .�/ �Q�Y Q t`/ }• dd� i /� f ,��,5' ❑ Stk' '466-6781- ❑ Lodi'a 369-3621-- '"p-Manteca 823-7 f04 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT-"DUE-_--.-._. .AMOUNT REMITTED CASH RECEIVED.BY '_. DATE _ —.PERM77wN0.� +.EH1241REV.F/H5Y ��j :,}.�` �• f ��,At T "I t:H 14- 4-2e - '