89-30 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. 649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District.. r Job Address7PVCity Lot Size PM Owner's Name Address Phone / ,' i 011 Contractor. w� Addsess License No. Phone TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER El DISTANCE TO NEAREST: SEPTIC TANK Si ER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AGR/ LTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON UCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ of Casing Specifications i 1-1 Public ❑ Other ❑ Del Depth Grout Seal Type of Grout I I irrigation Approx. Depth l astern Surface S al Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I! Depth Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C1 RE=PAIR/ADDITION I I DESTRUCTION o septic system permitted if public sewer is available within 200 feet.) 9 Installation will serve: Residence— Commercial— 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well F=oundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line -yam DISPOSAL PONDS ❑ I G 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 A ; rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 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 applicant MV0 call for all required ins p tions. Complete drawing on verse side. Signed X _ Title: Date f f-QR DEPARTMENT USE ONLY Application Accepted by ADate Area Pit or Grout Inspection by Date Final Inspection Additional Comments: 3 ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ 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 INFOFEECK 41 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By (DATE PERMIT'NO. +.EH13-24{REV.r/H51 '3S. �� d� EH 14-I6 Cf