89-2080 - Laserfiche WebLink

Home Browse Search

I l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT °J4 1601 E. HAZELTON 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 -1 Y 9l� '' City Lot Size PM Owner's Name Address 1 � ! Phone Contractor ddress License No. L Phone 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 i 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 n Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ WelbDiameter Sealing Material (top 50' ' 47 Depth Filler Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION tf 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: I Number of bedrooms t Character of soil to a depth of 3Yfeet: I Water table depth Nf-SEPTIC TANK El Type/Mfg -No. Compartments PKG. TREATMENT PLT. ❑ Method ofQis esel Distance to nearest: Well ndation Property LEACHING LINE ❑ No. & Length of lines 79 Total length/size FILTER BED ❑ Distance to.nearest: Well r ation Property Line �7 SEEPAGE PITS 1 I Depth Size A Number LIP S MPS: Ll Distance to nearest: Welldation Lin e Property Lin9 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 Calif ornia.'e'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;]shall employ,persons subject to workman's compensa- tion laws of California." F The applicant t c r al uir d 'ns tions. Com late rawing on rave i e I Signed X Title: Date: F R DEPARTMENT USE ONLY Application Accepted by —Date Area Pit or Grout Inspection by Date Final'Inspection by o Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi F 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 EE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. + EH 14-24(REV.��/x 51 r _— - '1