89-569 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JO.AQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address IJI.2 (2 57 City Lot Size PM Owner's Names Address Phone - Y-- 6�� Contractor 1 Address License No.30 S !�l PhoneJ9F'::?f-0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE= WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( 0 Industrial ❑ Open Bottom 4❑ Manteca Dia- of Well Excavation __ Dia. of Well Casing r❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i "� - ' Specifications f7 Public fel Other F1Delta Depth of Grout Seal Type of Grout 'I 1 Irrigation __,.Approx. Depth 1.1 Eastern Surface Seal Installed by'"� ! e Repair Work Done ❑ Type of Pump H.P. " 0 -L-State-Work-Done Well Destruction ❑ Well Diameter Sealing Material Itop-50',1 I Depth Filler Material If3elow'50 I — I /TYPE OF SEPTIC WORK; NEW INSTALLATION 1'1'REPAIR/ADDITION 1 1 DESTRUCTION I 1 iNo septic system permitted it public sewer is available within 200 feet.l a Installation will serve: Residence '._ Commercial_ Other I Number of living units: t Number of bedrooms \r1 Character of soil to a depth of 3 feet: Water table depth `v SEPTIC TANK Type/Mfg lr Capacity--&-(- No. Compartments — PKG. TREATMENT PLT. ❑ I ( Method of Disposal' �. distance to neatest: Well j f Foundation Q -- Property Line .74000 LEACHING LINE C No. & Length of lines��J�L� r Total length/size Q FILTER BED ❑ Distance to nearest: Well es Foundation 5 I Property Line oP OWI ' I I _ SEEPAGE PITS l 1 Depth 1 /61 _Size_._ � t — Number fi �Yu SUMPS L41'�Distance to nearest: Well 1561 Foundation I V' I Property Line oI-DLJ DISPOSAL PONDS ElI I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 shall employ persons subject to workman's compensa- tion laws of California." 1! The applicant ust call for all r aired inspections. Complete drawing on reverse side. Signed X �- Title: L AV A t Date: ��1- FOR DEPARTMENT USE ONLY Application Accepted by Date 2— 2= Area 1 t Pit or Grout Inspection by Date Final Inspection by Date 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 BV DATE PERMIT-NO. INFO �f CASH r.EH 13241RE\/.1/K5f 3�2z/fit �� EH 14-26 V