89-1684 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / r' Job Addressas M1.0 Y+ ® ( — City T� nt _ City Loi Size PM Owner's Name Ud1 Address 7 3 Phone f J - Contractor Address R7 r-11,ak, 'License No.��i'11one TYPE OF wFLL/PUMPY NEW WELL>< WELL REPLACEMENT'❑.3, DESTRUCTION ❑. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ fOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -r te SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL_,,— _-- PITS/SUMPS 11-0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f"' ❑ Industrial 'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - Xbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S13L9,12Specifications /0SYL [-I Public Cl Other F1Delta Depth of Grout Seal o Type of Grout__9. C I ! Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50' Depth Z Filler Material loeio 1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADD fTION I I DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.) r` Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms A. 4" Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK El Type/MfgCapacit`yr No. Compartments PKG. TREATMENT PLT. ❑ F'" Method of Disposal ] Distance to nearest: a Foundation Property Line- LEACHING LINE ❑ No..&'Legh of lines Total length/size FILTER BED �,� --0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size _ �' Number _ t SUMPS IA Distance.to -ft: Well Foundation Property Lin66' DISPOSAL.PONDS CJ .<� I hereby certify that I have prepared this ap kation 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 cbmponsatinn 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." 'The applicantJms&tall for allrequir d inspe s. Complete drawing on reverse side.� 13 l a Signed X Title: - Date: Jf I FOR DEPARTMENT USE ONLY Application Accepted by: /!/r - 'fDate +� �' / b Area Pit or Grout Inspection by' 72- Date 7 2 Final-Inspection by Date" Additional Comments: ~ y ! 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 y 0 Tracy 835-6385 .Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 f INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4t RECEIVED BY DATE PERMIT NO. +.EH 1324(REV.I/K 5) V .00 �� Y -1—1-7 EH 14-M