89-2024 - Laserfiche WebLink

Home Browse Search

1 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZEL T ON"AVE., STOCKTON, CA CU Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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: #76o Job Address Owner's Namg�'� e� City Lot Size PM , �� + Address70 0 0 C �Q1 d-r�c�C� Phone �0 Contractor e , ' T' f� Address & 47 (P '`' `!V5=& License No[ k 7 3 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ffr 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 0 Open Bottom ❑Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C1 Public ❑ Other - n Delta Depth of Grout Seal Type of Grout I I Irrigation —:Approx. Depth I I Eastern Su ece Seal Installed by _. Repair Work Done L1 Type of Pump H.P. State Work Done Well Destruction ' ❑ Wel Diameter Sealing Material(top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION't 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 _ ❑-- Type4Mfg-- __ _ - _„__ .__ _a rty_ �: {,b £omPartrr�ents PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No:A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well__, Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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,stats laws,-a 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 applicantM��7 eComplete drawing on reverse side. rry Signed X �"�Fitle: Date: �� FOR DEPARTMENT USE ONLY Application Accepted by ` Date ` , Area Pit or Grout Inspection by Date Final Inspection b Date%CSL ��%�y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835.6365 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95w1 INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY RATE PERMIT'NO. + EH 1 -24(REV.rix s) `�Jf'1 EH 114.28 / � V