89-1838 - Laserfiche WebLink

Home Browse Search

471 APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT JUL 31 1989 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 [NVI R WENTAL HALT!r PERMIT EXPIRES TYEAR FROM DATE ISSUED �S RVIC>=S (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 C�� 11 I City' ` Lot Size PM Owner's Name 7 e f Address Phone y— -6-4- s is Contracto,rr td c AddressL}��!`�' -�1� �� - License No. 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 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 i'l Public n Other C_l Delta Depth of Grout Seal Type-of-Grout ��` .. I i irrigation .w._Approx. Deptll I I Eastern i r Surface Seal Installed by Repair Work Done Ip.. Type of Pump �_ H.P. 1/, State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADD3IT4019 I ) DESTRUCTION l I INo septic system permitted if public sewer is - "� available within 200 feet.) installation will serve: Residence_ Commercial— Other i Number of living units: Number of bedrooms fes- Character of`soil to a depth of 3 feet: _ Water table depth .SE IC'TANK ` ❑ Type/Mfg Capacity No, Compartments C i PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size { FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( SEEPAGE PITS I'] Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an"--< 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m t�cal�a inspections. Complete drawing on reverse side. Signe Title: - _ Date: R DEPARTMENT USE ONLY / Application Accepted by Date L Area Pit or Grout Inspection by ate Final Inspection by Date — 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 CK At CASHL+ RECEIVED BY DATE T PERMIT NO. +-EH 13-241REV.5iHs! L /R3 EH 14.26 ! 2f J