89-957 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. f 7V 'al'udr �. City Lot Size PM Job Address �J j, "f a L 18tb k rw Phone W7 Owner's Name �'-e,�'f A"'e�l Address Contractor Address(' j �k ! "'License No. ? Phone TYPE OF WELL/PUMP: 'NEW WELL El'. WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ y... SYSTEM REPAIR ❑ # OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑,Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing 4 } ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy`• 4. Y Type of Casing Specifications FI Public Ll Other F) Delta t Depth of Grout Seal Type of Grout I l Irrigation _-Approx. Depth l 1 Eastern �. Surface Seal Installed by '4 Repair Work Done ❑ Type of Pump H,P. ' State Work Done ' I 1 Well Destruction [IWell Diameter Sealing Material )top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION la DESTRtfC.TION I I INo septic system permitted if public'sewer is ' _ available Ithin 200 feet.) .� O Installation will serve: Residence� Commercial_ Other _ � ,,�,,,. �-�•••- - I�'.+ Number of living units: Number of bedrooms _ = ` Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK Type/Mfg Capacity No. Ciimpartments PKG. TREATMENT PLT. ❑ t Method of Disposal e. Distance to nearest: Well Foundation Property Line _ '"""""W""�' k LEACHING LINE tor No. & Length of lines , Ttal length/size a FILTER BED Distance to nearest: Well Foundation 101" Property'Line t k SEEPAGE PITS l 1 Depth Size _ Number ; SUMPS Cl 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 accordande with San Joaquin county ordinances, slate laws, and rF' rules and regulations of the San Joaquin Local Health District. ; I 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: "I certify that in the performance of the work for which this permit is issued i I shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca for all requ'ed inspections. Complete drawing on reverse side. Signed X Title: 1 � -Date:- DEPARTMENT USE ONLY .P Application Accepted by Date •n/ Area Pit or Grout Inspection by Date Final.Inspection by Date y 4 Additional Comments: 13Sik 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-6385 3 Applicant - Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEEAMOUNT DCJE`"" --AMOUNT,REMITTED CASH RECEIVER f3Y' DATE S PERMIT NO. t INFO ♦.EH 13-24(IRM EH 14-26