89-1500 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL 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 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. Job Address Cit Lot Size `PM r/ t ' Owner's Name '' '+-� ""�'Address Z✓�/t�/y2 zr✓cr��-L"e- Phone 2.2, Contractor ��a*��— Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAID OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR,E,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/Private ❑ Gravel Pack -n Tracy Type of Casing Specifications I1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- I rout _I I Irrigation �WeIlDifameter dx. Depth 11 Eastern Surface Seal Installed by _ Repair Work Done ❑ ump H.P. State Work Done Well Destruction ❑ Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTTC WORK: NEW INSTALLATIONI REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is yy available within 200 feet.) Installation will serve: Residence /X` Commercial_ Other Number of living units: Number of bedrooms Character of soil to a dept f 3 feet: �j Water table depth SEPTIC TANK ;Type/Mfg dyke`'. E=-L�rc �, Capacity_f�O,o No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well SC Foundation /V Property Line j Y � ' LEACHING LINE No. & Length of lines � '-� �-4? M Total length/size FILTER BED ❑ Distance to nearest: Well,X?C" Foundation Property Line SEEPAGE PITS VK Depth Size 3 _ 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 Califomia."Contractor's hiring or sub-contracting signat 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 quired inspecti Complete drawing on reverse side. Signed X Title: tl Date: 67,1 ` FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit r Grout Inspection by ate JFinal Inspection by Date 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 DATE PERMIT'NO. a EH 13.24(REV.t/x 5) Sr- �/r2w•` EH 14.28