89-1108 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT C� SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U (Complete in Triplicate) j 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 Rpdulations of the San Joaquin Local Health District. ";j 7/i �`�'Z / Cit Lot Size O' PM Job Address Y viOwner's Name G l"7 e-Address � ' Phone �� Contractor fir..-- f Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a, l') Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Iruga�tion _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Delstruction ❑ Well Diameter Sealing Material (top 501 Depth'° Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION { 1 DESTRUCTION l I (No septic system permitted if public sewer is �] available within 200 feet.) r— t Installation will serve: Residence Commercial_ Other cf t Number of living units: .Number of bedroo s + I Character of soil to a depth of 3 feet: ��I7 t./ /f c Water table depth SEPTIC,TANK Type/MfgCapacity U No. Compartments PKG. TREATMENT PLT. ❑ y � Method`of Disposal ✓1�� ' Distance to nearest: Well h �j 'pFoundation � Property Line LEACHING LINE ❑ No. & Length of lines n Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth �0[ e _ Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line a 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 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 I employiany 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,l shall employ persons subject to workman's compensa- tion laws of California." } ` The applicant st all for all(q6u_iradJ ek lete drawing on rever side. Signed X Title: ` jo Date: t F. EPARTMENT USE-ONLY''' Application Accepted by 4 ` Date / Area y �or Gro��en by a Firial.Inspection by Date Additiol- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 ' ti Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 as INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT-NO. +.EHs13.24(REV 1/x5) f� EH 14-2e