89-2301 - 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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hefeby 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 14- Owner's . Job Address Cityl •"'Lot Size PM Name V `WTA%ddress �Oy Phone qs 469 Contractor �"VVI.. AddressC4ZTtLicense No. /M Phone v TYPE OF WELL/PUMP: NEW WELL IK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO �� SYSTEM REPAIR ❑ OTHER ❑ 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 �w Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 7 VC, Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Q Type rrof``Gr /t I I Irrigation iZ .Approx. Depth I I Eastern t Sace Seal Installed by t lRepair Work Done Ll Type of Pump �� H.P. ( L. State Work IULne� Well Destruction ❑ Well Diameter Sealing Materia`(top 501 9 Depth x Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADEIITION t l DESTRUCTION I I (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 t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL P DS ❑ I her ce ify t at I ha prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and r gula ons o th San Joaquin Local Health District. Home ow 4'rons d a nt's signatujfmJeb rtifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ an uch nor a oct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies thng: 'I ce i tha m tof the work for which this permit is issued,I shall employ persons subject to workman's compensation laws nia.The ap icqu ed iomplete drawing on reverse side. ''j'� Signed X Title: Date: F9 FOR DEPARTMENT USE ONLY Application Accepted by Date t/ Area Pit 40n nspection byoi�l Date Final Inspection by J �� Date Z j J tS 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY rDATE PERMI^T'�NO. + EH13-241REV.iiH5l 1 �C-� EH 14-26 -