89-1177 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 andlor install the work herein described.This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address — 4 At, W,4I$ .T City Ts'�c�` Lot Size 6a 14cyes PM ` �Y � �� Phone Owner's Name gb 8 TTS f Address Sr/ Phone t J'ga�wx q/ Sary Address a�Z 8�� v �'` License No. yy_.�`- i Contractor DESTRUCTION L1TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT 171 A, +A .`SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION'^❑ SEWER""LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK i .,FOUNDATION 1 AGRICULTURE WELL.— OTHER WELL PITS/SUMPS 1 INTENdED USE'4"1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia.,of Well Casing C. r ❑ Industrial '+".0 Open,Bottom .a 'Manteca Ria. of Well Excavation w^ Specifications — ❑ Domestic/Private —L1 Gravel Pack J. ❑ Tracy} ' Type of Casing , 1 Depth of Grout Seal ' `)Type of Grout f'1 Public f 'i %r fl Other -, Cl Delta ! R ' Surface Seal Installed by I�l-Ifrigatiori ),Approx�. Depth l_I,Eastern�,t K r Y . State Work Done 4 Repair Work Done ,0 Type-Of Pump,: H:P. y` Sealing Material (top 50') Wel! Destruction ❑. Well;Diameter" } Qeptht T *' ;filer Material (Below 50') i TYPE OF SEPTIC WORK: Nf=W INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I i aNailabPe1with5ne200 feeft�edrif^public sewer is l �'"----.-"ice_---�..,....u�- ., +�r°r-�•-..""°�'-. _- ' t Installation will serve: Residence Commercial_ Other Number of living units: Number-of bedrooms Water table depth f Character of soil to a depth of 3 feet: No. Compartments T elMfg w Capacity �� SEPTIC TANK ❑ .4 YP - r �' [tiAi:tliod,of Disposal i PKG. TREATMENT PLT -❑�I �" 00 k ,U w:, 00 Foundation Property Line y a, Distance to nearest: Well _ � Total fengtti/size ` r LEACHING LINE ❑ No. & length of lines' 1200 zoO, Property Line'-�D• ` y 4 FILTER BEDS G X Distance to nearest: well Foundation } /]4'x /40 Number 16 U SEEPAGE PITS l I Depth Size Property Line SUMPS L-1 Distance to nearest: Well Foundation r t:. 4M DISPOSAL PONDS ❑ # m E that,the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 hereby certify that 1 have prepared this application and 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 far which this permit is issued, I shat! not employ any person in such manner as to become subject to workman's hiring or sub contracting signature compensation laws of California." Contractor's I certifies the following:"'I certify that in the performance of the work for which this permit is issued, I shall employ persons*ubject o workman's compensa- tion laws of California." 1 The applicant must call for all required inspections. Complete drawing on r Title: Date: Signed X -t,_� ^ R DEPARTMENT USE ONLYtas / e � r r Application Accepted by Date / ' Final Inspection by Date kPit or Grout Inspection by Date_��—- Additional Comments: I ' 11 Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 635 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. ? INFO �y ^-� f a EH 13-24{REV.t/H 57 (} T l EH 14.26