89-986 - 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 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. tt /� f /{�� Job Address 2-.j J 0 S`o crA �/ ` e Qh de✓� City / • N�E Lot Size O PM Owner's Name G 6, r Address\! �2 Phone Q Z 3 —4D 2s� Vr'AJC-tLA, NVLUM,?lN Contractor -Address�� License No. lq" Phone 5 , A7 TYPE OF WELL/PUMP: NEW WEJ.�r- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4THEFF O�� DISTANCE EAREST: SE SEWER LINES DIS_OSAL FLD~ PROP. LINE TION AGRICULTURE WELL �JOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 4 AREP,_—C' NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Nia ca ell Excavation_ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public F-1 Delta Depth of Grout Seal Type-of-.Grout I I litigation --Approx. Depth l I Eastern Surface Seal Installed by R.epa' ork Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') C! . Depth Filler Material (Below 50 TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is lI� available within 200 feet.) Installation will serve: Residence AL, Commercial_ Other Number of living units: _I ..__ Number of bedrooms _ Character of soil to a depth of 3 feet: T Water table depth ° SEPTIC TANK ❑ Type/Mfg Capacity-4200 4 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well . Foundation 3ye Property Line /^,D r-� LEACHING LINE KNo. & Length of tines Total length/size o'er FILTER BED ❑ Distance to nearest: Well /D Foundation 7500 Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ 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, state laws, 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 for which this permit is issued, I 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: "If. rI fy 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 applican ust c required inspections. Complete drawing on reverse /side l� Signed X Title: Date: FOR DEPARTMENT USE ONLY �* Application Accepted by Date S rea Pit or Grout Inspection by Date Final Inspection b Datt� Additional Comments:R4 c +� ,� �-• _ `�_.-� L ,zs.11L ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6 8 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH j RECEIVED BY DATE �7PEE,RMIT'NO. + EH13-24 RI EV.t/x 51j4, EH 1129 VVV ([ &.A {J /' V