89-3001 - Laserfiche WebLink

Home Browse Search

s 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, pC9S-alCJO-�� CityLot Size L PM Job Address Owner's Name Address C ` Phone , - Contractor f Address L"cense No.nnfl_Phone�yfs .TYPE OF WELLIPUMP: NEW WELL ❑ rR EPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ STEM R R ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW DISPOSAL FLD. POOP, LINE FOUNDATION AGRI WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM STRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Man a . of Well Excavation Dia. of Well Casing ❑ Domestic lPrivate ❑ Gravel Pack ❑ cye of Casing Specifications i'1 Public ❑ Other Deltath of Grout Seal Type of Grout ---- e I Irrigation __,.Approx. Depth I I Easternace Seal installed byRepair Work Done ❑ Type of Pump H.PState Work DoneWell Destruction ❑ Well Diameter Seaial Itop 50'1Depth Fille (Below 5D') -- TYPE OF SEPTIC WORK: NEW INSTALLION REPAIR/ADDITION I I DESTRUCTION-1 1 (No septic system permitted it public sewer is {r!/ available within 200 feet.) Installation will serve: Residence_ Commercial..— Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: 4 n 4 Water table depth t SEPTIC TANK• ❑ Tyke/Mfg Capacity2� No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disnoghl Distance to nearest: Well Foundation U Property Line LEACHING LINE. ❑ No. & Length of lines �1 To al length/size FILTER BED ❑ Distance to nearest: e l its nn Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well oundation 16 Property Line DISPOSAL PONDS 0 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, ands 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 suhject 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 t call for uired ins tions. Complete drawing on reverse side. Signed X Title:�L� g�/ Date: �— FOR DEPARTMENT USE ONLY ^7��'� Application Accepted by Date o n�_�+ Area it r Grout Inspection by Date Y p-final Inspection by /"� ate Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO" CASH t EH 3-241REVt/A51 ?! �00/ EH 11