89-2234 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON AVE., STOCKTON, GA I 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 I Local Health District. t 1 Job Address !'�' 3/,-b! » ,,_,,., _ City Lot Size G PM ` t Owner's Name yj /�2B, e`�go_ Address .mac Phone Conlraclor 09 ��dr! T Address License NoPhone TYPE OF WELL/PUMP: ``. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑,+�" PUMP INSTALLATION El SYSTEM REPAIR ElOTHER..❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. Z PROP. LINE FOUNDATION AGRICULTURE WELL OTHER'WELL Z PITS/SUMPS _ INTENDED USE:.. . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS/ ❑ Industrial ❑ Open Bottom -❑ Manteca Dia. of Well Excavation "oe Dia. of Well Casing ❑ Domestic/Private C7 Gravel Pack ❑ Tracy Type of Casings �� _ Specifications I M Public 17 Other f] Delta Depth of Graut Seal Type of Grout---- I rout _! I Irrigation —.-Approx. Depth 1 1 Eastern Surface Seal Installud•by Repair Work Done El Type of Pump H.P, - r State Work Done_ Well Destruction ❑ Well Diameter : Sealing Mater al [top 5 1'y I DepthFiller;Material TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION I,I' DESTRUCTION] I (No septic system permitted if public sewer is f available within 200 feet.] - Installation will serve: Residence Commercial •'1F Other/ :� Number of living units: _ ._Number of bedrooms _.__,_,/r Character of soil to a depth of A feet: Water table depth E SEPTIC TANK ❑ Type/-MfgM""�'' "Capacityo4p 49 P No. Compartments a PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well. e Foundation Propeny`Line �� t•3f N LEACHING LINE Jie No.-&,length of I nes yTotal 1ength/size V 7— FILTER BED O❑ 3tance to nearest: WeII �Faundation ' 1jProperty Lined SEEPAGE PITS � +'i I Depthr ? �7' —Size'' + '�(�.� Number SUMPS r 11� Distance to nearest: Well�Q.��Foundatian _'Property Lir3e ' /,. 1 DISPOSAL PONDS LJ I hereby certify that f have prepared this applicatjon and that the work will be done in accgrdance with San Joaquin county ordinance-, laws, and j rules and.regulations,of the San Joaquin Local Health Di§trict. i i k Homa Qwner or iicensed agent's signature certifies the'Jollowing:"'I certify that in the perfoimance of,the work for which this permit istissued,sI shall not ertlpltiy any person in such manner as to become subject-to v4orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "!certify that in the performance of the work fowhich.this permit is issued, I shall-employ persons subject to workman's 4ompensa- k tion laws of California." \eC /f The appicl t ant must call for !Squired inspections. ompete&awing'on reverse side. sign! Xa Tine: i .i"^ Date: a. 1 1 ,.' FOR DEPARTf111ENT USE ONLY Application Accepted by I l Date IA`rea i .. r Pit or Grout Inspection byrDate �`•�t � ' Final Inspection by ate 9 !/ � Additional Comments: �� ev0 f �' - - �L - ,O.S'A,� I a"leGC_ ri ttir n�� !e ❑ Stk 466-6781 El Lodi 369-3621 Q'Man#eca f323Q7r104 f �`❑ Tracy 835-6385 Applicant - Return all copies to: Environmehtel Health'Pe�rhit/Services t601;,E. Hazelton Ave., P.O. Box 2005, Stk., GA 95291 I • CK t rFEE AMOUNT_DUE:....�.—AMOUNT•REMrITTfD�- --C SH 1 "' FlECENEDIRY Y—D-ATE "1•PE9K1I* 'f415. 1 l gG y. EH 14-26 l` Z� 07"`Z��l_fl i