89-676 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA fr 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 J(93 91 10C &9 City City Lot Size PM Owner's Name address X/ 11=--C- r9u 'rs t� Phone . Contractor � ddress License No. �QI� TYPE OF WELL/PUMP: NE WELL � �J U Phone ! % WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK r '1`' OTHER ❑ SEWER LINES = DISPOSAL FLD. L-- t FOUNDATION _ _ AGRICULTURE WELL pp .__.. PROP. LINEL ;L� OTHER WELLPITS/SUMPINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS❑ Industrial ) Open Bottom ❑ Man❑ Domestic/Private Dia. of Well Excavation Dia. of Well Ca❑ Gravel Pack ❑ Tracy T❑ Public YPe of Casing � J F] Other 11 Delta �"�'i L` Specifications Depth of Grout Seal __ �Vlrrigation ,�pprox. Depth l I Eastern Type of Grout Repair Work Done ❑ Type of Pump Surface Seal Installed by 1-1 Well State Work Done Well Destruction Z> WeII Diameter« — _ Sealing Material (top 50') Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t 1 DESTRUCTION I I (No septic system permitted if public sewer is �+ Installation will serve: Residence_ Commercial__._ Other available within 200 feet.) �... Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ ----- Capacity____ No. Compartments r Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE El No. & Length of lines FILTER BED ❑ Distance to nearest: Well __ Total length/size Foundation__— property Line SEEPAGE PITS I I Depth SUMPS Size _ Number Ll Distance to nearest: WeII DISPOSAL PONDS ❑ Foundation-_____ Property Line 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 tion laws of California." p p y persons subject to workman's compensa- tion applicant m c a require ." /; s. Complete drawing on rev �e side. Signed X �'`� Title: Date: FOR EPARTMENT USE ONLY Application Accepted by 'IT� �� Date V— Area OF Pit or Grout Inspection by Date Final Inspection by Additional Comments: Date ❑ 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 AMOUNT DUE INFO AMOUNT REMITTED CK CASH RECEIVED BY +.EIt H 13-24(REV.t i x 5) DATE PERMIT NO. EH 14-28 �t�yl \O Vr