89-416 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT y� SAN JOAQUIN LOCAL.HEALTH DISTRICT ! 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED (Complete iri 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 y 'u 41City Lot Size PM Crr , -dam O Phone Owner's Nam-kAAddddressss / Contractor r,4 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 0 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'l Public [=1 Other ❑ 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 ❑ Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 50'1 - — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence— Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Prope`y Line f+x LEACHING LINE ❑ No. & Length of lines `•''; Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property-Liner t 't SEEPAGE PITS I I Depth Size Number 4 SUMPS- 0 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 Di$trict. 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 became 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 st -F-ii requir inspecti ns. Complete drawing on reverse side. Signed X r 1 Title: Date:. FOR DEPARTMENT USE-ONLY Application Accepted by __. _. Date Area �N-, Pit or Grout Inspection by Date Final Inspa tion by 5� Date Additional Comments: C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 JV Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CSR RECEIVED BY ,DATE PERMIT'NO. INFO p� .. + EH 1324(REV.1/H 5) 3 EH 14-26 !/ t.