89-1614 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. z a/' Job Address 'r te� C� - City Lot Size ` z�PM �7 Owner's Name J_ �� /Y��✓'w C.�+ Address � [ G Phone Contractor SLC Address G License No A Phane TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ "" OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CdNSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a X1.Publics__ _.., (�Other.,___„ , _.t 1-Delta___ ___ _ Depth.of Grout Seal _ _Type-of_Grout I ] Irrigation .__..Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done D Type of Pump H.P. State Work Done s Well Destruction ❑ Well Diameter Sealing Material Itop 501 p 19 Depth Filler Material (Below 50') TYPE OF SEr'TIC WORK: NEW INSTALLATION (#I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is. ttt available within 200 feet.) ? _ fir.—�.rve..- ' Installation will se : Resid nce Jr Commercial_ Other Number of living units. "Number"of rbedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ �- �� Capacity- 60 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: . Well-ll - Foundation 1S Property Line LEACHING LINE ❑ No. & Length of lines C:.0 � Total l---ength/size FILTER BED Distance to nearest: Well ,�2,� Foundation�_"� Property Line r ^:LI s SEEPAGE PITS r. I I Depth Size " + Number SUMPS Ll Distance to nearest: Well Foundation / Property Line DISPOSAL PONDS ❑ ryt } 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:"l certify that in thojperformance bf 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 Califomia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issded, I shall employ persons subject to workman's,compensa- tion laws of California." The applicant must c I for all requirrad inspections. Complete drawing on reverse side. Signed X.__ Title' ' I Date: r FOR_DEPART_MENT USE ONLYti- J+ '1 r ADate Area Application ccepted by ' Pit or Grout Inspection by Date Final Inspection by`f Date . y s 'Addition'al:Comments: 1 L] Stk 466-8781 . ❑ Lodi 369-3621 ❑ Meriteca 823-7104~' i'D Tracy 835-6385 Applicant - Return,all copies to: Envirannmeental Health Perm it/Services 1&11 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { FEE AMOUNT DUE AMOUNT REMITTED~ CK RECEIVED BY yf)ATE PERMIT`NO. _ INFO• _ .CASH--. +.El, 1324 IREV.1/H57 i EH 14-28 1