89-439 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 GS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �V,��{QoS�pN 1 (Complete in Triplicate) c NVQ AtN,k�`^ f1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or)n tarl fieue)FS' �^��' ?►This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for w I ct1$3ir71�s aid e ions of the San Joaquin Local Health District. S� Job Address (_AUL✓ +� S ' S l City Lot Size PM Owner's Name '/ ,(�� Address G , t` ��q�G��l/2 Phone Contractof " Lv�--v' M� IP ,/Address License No, 2 Phone T— TYPE OF WELL/PUMP: NEW WELV4--f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOf 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 SPECIFICATI S Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing / ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing �� — Specifications /1CGQl 17 Public Other/NWW / 171 Delta Depth of Grout Seal l�� Type of Grout_ _ I I Irrigation / _Approx. Depths�� ''l��IjEastern Surface eal Installed by 104 t � - Repair Work Done ❑ Type of Pump H.P. ! State Work Done_ Well Destruction ❑ Well Diameter Sealing Mat ial (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) 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 Foundation Property Line SEEPAGE PITS I I Depth Size _ Number _ SUMPS Ll Distance to nearest: Well Foundation Property Line 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, st laws, and rules and regulations of the San Joaquin Local Health District. ,C Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whic;;l1��t r1i�`,�d, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Cont �firr i�r VbvLtracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I�sw, l6 tpetvorkman's compensa tion laws of California." �� The applicant mu all r al equired inspections. Complete drawing on reverse side. y Signed X Title: /.�71ZIA1.6 (.O�O ?.J� Date: �`( FOR DEPARTMENT USE ONLY Applic tion Accepted byData Area Pit or Grout Inspection by Date Final Inspection by Date !� Additional Comments: c �' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 del C/ Aw INFOFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH13-24(REV.i/H5) -e- 3s- -O 3-3-y I Yy-'137 EH 14-26