89-1617 - Laserfiche WebLink

Home Browse Search

-z3 �� T� APPLICATION FOR PERMIT Pp SAN JOAQUIN LOCAL HEALTH DISTRICT �i 1601 E. HAZEL i ON AVE., STOCKTON, CA '� "'Telephone (209) 466-6* C� � d PERMIT EXPIRES 1 YEAR.FROM.DATE ISSUED ��itl ,r {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. -rrt •„ � Gni 7 Job Address City Lot Size20 IPMT^�a Owner's Name ( GtJ�i Address Phone [� fff Contractor rt Address 1 �e-� License No. v Yv Phone ! E7r� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION w PUMP INSTALLATION } SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK .-� SEWER LINES DISPOSAL FLD., o PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA 4 CONSTRUCTION SPECIFICATI91 IS �? ❑ Industrial ❑ Open Bottom ❑ Manteca ,bia. of Well Excavation Dia. of Well Casing Domestic/Private I�YGrave! Pack ❑ Tracy Type of Casing Specifications,.=` ❑ Public ❑ Other ❑ Delta —'Depth of_Grout_Seal:----- t K7.'Ty e of Grow ❑ Irrigation �pprox. Depth �y❑ Eastern Surf a Seal installed by !� �� ! Repair Work Done O Type of Pump S ar H.P, l ! State Work Done cr l r Well Destruction Well Diameter Sealing Material {top 501 GCJtdt .<'• p Depth 4 Filler Material (Below 50') _ �E G.-. C tor— TYPE or -TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ :DESTRUCTION ❑ (No septic system permitted if public sewer i available within 200 feet.) Installation will serve: Residence— Commercial_ Other e % Number of living units: Number of bedrooms ► " 1 Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ [ Method of Disposal Distance to nearest: Well Foundation Property Line may= LEACHING LINE ❑ No- & Length of lines f; J Total length/size i FILTER BED ❑ Distance-to-nearest::k`� W\ 1e11 Foundation - Property Line SEEPAGE PITS ❑ . Depth Size " 4x tT Number " J SUMPS ❑ .Distance to nearest: Well ,3 0 undation �� 1:., ,. PropertyLine DISPOSAL PONDS ❑ f f l 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. L 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." rd ; The applican s all for all require qsPecti s. Com ete drawing ow-1•ever¢a side. J s 9 / p / ^ s Signed ` Title:' re— Date: t FOR DEPARTMENT USE ONLY t r } Application Accepted by Date Area { Pit or rout spection by i]ate' IfFinal-Inspecti o"ri: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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY. DATE PERM17'N0. 'SOS °` �� + EH13241liEV:tix5f 7 EH 1429 _ TE