89-1766 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT /� SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1601 E. HAZELTON AVE., STOCKTON, CA 'J1 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 I 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 "gvxe Pi., Job Address City Lot Size PM Owner's Name `2 ` Address S47Y'C Phone a Contractor Address License No.,O�Phon,�I6 � 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 i I7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation t 1 Approx. Depth I l Eastern Surface Seal Installed by ^' Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 50') _ �! I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is 4 available within 200 feet.) r Installation will serve: Re 'dance v Commercial_ O er # I y t Number of living I units: Number of ?e ooms { r ( Character of soil to a depth of 3 feet: } Water table depth I r t SEPTIC TANK ,, ❑ Type/Mfg Capacity '. _ No. Compartments' PKG. TREATMENT PLT. ❑ ` '` `l _ Method of Disposal rn / Y Distance to nearest: Well Foundation Property Line LEACHING LINE Qj,—No. & Length of lines ___C1 2 r X Y-0, Total length/size g �� Lein 1 FILTER BED f ❑ Distance to nearest: Well 9 Foundation e2 r 'Property Line SEEPAGE PITS P'l Depth ��^ Size W N Number SUMPS ! ❑ Distance to nearest: Well.495 Foundation 0 l 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 Di1trict. 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." s The applicant-must call for all r uired inspections. Complete drawing on reverse side. f Signed X_�/J _ - Title: Date: { FOR DEPARTMENT USE ONLY Application Accepted by Date ,2 �/� Area e2 Pit or Grout Inspection by Date Final Inspection by Date 7A .� .�.��..��—,ter-,-.,.......-..-.....-.. _ ......-.��r I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 "❑ Tracyw-835-6395 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +,EH1324 IREV.i i n sl EH 14-26 i I