89-456 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT -- s-: ' e t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe 12091 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-f or-well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ® City Lot Size 8d li' PM 101-0 � i Owner's Name Q1_1 &It & Address hone to 700 Contractor _�J 9c� ��os r -Address d icense No. dw/ PhoneQ63 IMI TYPE OF WELL/PUMP: NEW WELL ❑ WELLWEPLAC�ET ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, ❑ Domestic/Private ❑-Gravel Pack ❑ Tracy Type of Casing Specifications. ('1 Public n Other ll Delta Depth of Grout Seal \ Type of Grout*'_ j I I Irrigation —.-Approx. Depth t I Eastern Surface Seal Installed by } Repair Work Done ❑ Type of Pump H.P, State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 In i Depth Filler Material IBelow 501 ! i r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) } i Installation will serve: Residence— Commercial_ Other? Number of living units: -0— Number of bedroom f I Character of soil to a depth of 3 feet: inti Water table depth SEPTIC TANK ❑,,,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal `� ,� Distance to nearest: Well 16� Foundation 13CL Property line LEACHING LINE No. A Length of linesr d6,®+ ®� Total lengthlsize FILTER BED ❑' Distance to nearest: Well Foundation �'Property Line SEEPAGE PITS t I Depth CEJ` Size K� Number � SUMPS L] Distance to nearest: Well Foundation 13 577_ Property Line 26' DISPOSAL PONDS Q i 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 i 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, I shall employ persons subject to workman's compensa- tion laws of California." The applic t must call for all required i ctions. Complete drawing on reverse side. Signed X Title: %�1(a Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by t `"w`^'_ t Date'-1-6— 89 Area Pit or Grout Inspection by _ ate l ! Final Inspection by4:r Date V Additional Comments: j ❑ Stk 466-6781 C1 Lodi 369- 1 ❑ 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 y I INFO FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. EH EH t3-241 (REV.rins) Sao 141J2 1-2a J