89-935 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Owner's NameQ�- ,Address t t I ZJ Phone Contractor kl � Address c P (I License No/41373 Phon 694 94 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 _ 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 ❑ Tracy Type of Casing Specifications F1 Public Ll Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done LX Type of Pump - H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 4A El TANK Type/Mfg Capacity No 14 Lit% PKG. TREATMENT PLT. ❑ Me Isposal 54 Distance to nearest: Well Foundation Property e APR 27 1989 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line FNVIRONMUffAI HEA11H SEEPAGE PITS I I Depth Size _ Number PERMITISERVICES 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 t cal r all re uire inspections. Complete drawing onreverse side. _ ] r Signed X �–�ct �"7'Rte: Date: FOR DEPARTMENT USE ONLY /� ,yt✓/) Application Accepted by � Date Area Pit or Grout Inspection by Date Final Inspectionbvl ,] h Date e� 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. +.EH13-24(REV.1/85) 3�( qq EH 14-26 Q \ �.?