89-660 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City ize PM Job Address /� � (� IOwner's Name + a L ddress 81�n JP 1 Phone 4Y� — f � Conlr osl^�Idress (Q � S 1'7Q�MenseNo.ZazZ��Phone 3`C) TY E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND ON AGRICULTURE WELL OTHER WEL ITSISUMPS INTENDED USE TYPE OF WEL PROBLEM AREA ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Trac Type of Casing Specifications 1-1 Public Cl ❑ Delta Depth of Grout Seal i Type of Grout I Irrigation C_Approx. Depth I 1 Eastern S e Seal Installed byRepair Work Done ❑ e of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 50'1 Depth Filler Material {Below 50'I -- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION rKMo septic system permitted if public sewer is vailable within 200 feet 1 Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal +� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size T Number SUMPS 0 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 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 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." The applicaall Wall uireA in ctions. Complete drawing on reverse side. Signed X Title: �..L� 1/�CYtr2. Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by DateArea C� Pit or Grout Inspection b Date Final Inspection by Date 1 Additional Comments: 196172 ❑ 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, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH1 -24iREV.r/x51 EH 144-26