89-579 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Distnct 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City - i Lot Size_ PM Owner's Name .— Address Phone -- ZU ContractorAddress License No. Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT V DESTRUCTION ❑ MD i, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X Qinl x(!,40 eo rY DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE �� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y�r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation rf Dia. of Well Casing 4` F. Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications /10 - i.`l Public 1 Other I1 Delta Depth of Grout Seal Type of Grout_ 1} Irrigation ��.Approx. De th // I I Eastern Surface Seal Installed by— Repair y Repair Work Done 71 Type of Pump K1`!9 .vP H.P. /d_ State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') 444 L4 "AA Depth Filler Material (Beiow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION € 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence___ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments lr.•®1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl 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 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 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 call for all req fired inspections. Co plate drawing on reverse side. Signed X Title: ._ A-.t7a,, Date: 3 -.926* FOR DEPARTMENT USE ONLY Application Accepted by _,t,'2 Date �-.-Z� Area Pit or Grout Inspection by Date Final Inspection by �� Date c/ 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 2409, Stk., CA 95201 FEECK INFO AMOUNT pIJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH13-241REV.i%esl � � .}'1 ' jQyry EH 14-26 ..✓✓ r ':