89-1443 - Laserfiche WebLink

Home Browse Search

APPLICATIONtOR PERMIT SIGN JOAQUIN LOdAL•'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6'914.. PERMIT EXPIRES T YEAR FROM DATE ISSUED s ` " (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 Sen 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 H Job Address W JELLQ rw s City _ Lot Size PM_ Owners Nar " w�rr i!i!_ Address 611 GIN, CWT4 Phonek -Z7 t' *430 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE$ ,; SEPTIC TANK, ,!10 SEWER LINES, DISPOSAL FLD. PROP. LINE FOUNDATIb! __,.,j_, AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAS COOSTRUCTION SPECIFICATIONS C7 industrial °` ❑ Open Bottom ; ❑ Manteca Dial of Well Excavation Dia. of Well Casing __- 11 Domestic/private ❑ Gravel P k ❑ Tracy Typb of Casing_ Specifications (1 Public 1=1 Other 1 a"` ' C) Delta Depth of Grout Seal Type of Grout______ I I Itrigation Approxi t4flih. I 1 Eastern Surface Seal Installed by Rep94 Work Done 0 Type of Pump H.P. Stath Work Done_ Well 6"ttuction '❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I) REPAIR/ADDITION I 1 DESTRUCTION 74INo septic system permitted if public sewer is - ! available within 200 feet.) Installation wld satin: R 'dance. 1'�d6ltimert ial Other Number of living units: Number Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg 'Cappeit lud No. Compartments PKG. TREATMENT PLT.❑ ' s Method of Disposal [1lstariGt! f Well. Foundation " Property Line LEACHING DINE ❑ No. b Lek gth Yf lines Total length/size FILTER BED 0 Dista ff ` t6 Well Foundation Property tuittri SEEPAGE PITS I 1 Depth y4 *r I Size Number SUMPS .Cl .Distitrice to test: i Well Foundation Proferty Line D SPOSAL ND'S ❑ ,_ ', I hereby certify that 1 hava ptoohlId tftis joOk stion and that the work will be done in accordance With San Joaquin county ordinances, state Taws, and roldi and toodlatlofiti of,the Ban G6M Hbalth Di§trict. Home owner br Ik:insed agertt's 4MII14 the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ*W 0#00 in such itl WO&8614;b'k6mb lubject to Workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the ng:` tify 1 certhit in tfNl p�f&WAnce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of fftrtiis: ; The appilca iittrat tot eM req irad sp�Eltiortp. Complete drawing on r rse side. Signed t s Title- Date: (-�# ` g -- � ww $ s OR WARtMtNT USE ONLY t C Application ACDept6d by Data I Area 1 Pit or Grout Inspectlan by ; - I afa Final Inspection by Date Q �� Additional Comments: a : Stk 4M4M. O Lodi M .. b Minteca 823-7104 ❑Tracy 835-8385 Appileant- R*Wto t8)wpbs to: Envirbiinel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 K 8 INFO AMOUNTtSt1E AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'ND. EM1124(REV.t MiRst t✓ �� r��✓ ��r� �� 7`Y,� FH 426