89-1579 - Laserfiche WebLink

Home Browse Search

"i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED., fComplete 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. j Job Address 1672 L Rowmen Rd City L 2tTSize.. �- - PM ,Tames SilVeria Address— 5 - Owner's Name Phone 4408 Contractor Owner Builder Address a S aboYe ___License No.-N-4a—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 Cl Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ED Other Ll.Delta». Depth of Grout Seal Type of Grout--.-- I rout__.I I irrigation Depth i I Eastern Surface Seal Installed by - Repair Work Done L7 Type of PumpH.P, State Work bone_ Well Destruction © Well Diameter Sealing Material (tap 50'1 Depth Filler Material (Below 501 - - TYPE OF SEPTIC WO K: NEW INSTALLATIONXI REPAIRIADDITION I l DESTRUCTION I l 1No septic system permitted if public sewer is —a"vailabI within 20016et-1 Installation will serve: Residence Commercial-�L- Other Number of living units: Number of bedrooms - -f/tAlfipl' Character of soil to a depth of 3 feet: 1_"� R- W9ter table depth SEPTIC TANK IN Type/Mfg P&L water T i h t Capacity/20 0 No. Compartments t PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CR No. & Length of lines 3-8 0 f o o t Total length/size 240 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line I 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 District. Home owner o icansed 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 p s n_in.such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fa to ing: "I certify thavin the performance of the work for which.this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C l.1 rrnai. The applicant u t call for all required inspections. Complete drawing on reverse sl'ider Signed X Title: lwJ+V Date: ?��/ r FORD PARTMENT USE ONLY _ Application Accepted by Date�-��-� ,Area r `, Pit or Grout Inspection by Date Final Inspection by Date r l [ Additional Comments: 7 �'U^ it-'P' ��r� --R I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ment ca 823-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE Al410UNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO +-EHi3-24IREV.r/951 ��/ -7f� �" 9 EH 14-28 4 I a"t 4 r�/