89-2343 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZELTON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in7riplicate) 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 Cit�tel/ /Gs0/ �sJ. QIF - 19 - k y Size PM Owner's Name Address /L Phone Contractor Address ?yJ License No.3Pf2�Phone 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth ( I Eastern Surface Seal Installed by ~ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material 16elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION I I DESTRUCTIpN I I (No septic system permitted if public sewer is "T- ""`"d available-Within 200 feet.) Installation will serve: Residence Y Commercial Other .a a \` : r Number of living�ts:"� Number of be room .:*- J Character of soil to a depth of 3 feet: �.- Vi - Water table depth SEPTICTTA KpTypi/Mfg ' -r Capactm '77ity-, No. Comparents «PKG. TREATMENt PLT. ❑ � ,, £- �° 4 F. *)Method of Disposal Distance to nearest: Well Foundation Property,.Line LEACHING LINE ❑ 'No. & es Tota! len size ,Length of linth 1 ILTER BE- ❑ Distance to nearest: Well Foundation _ Property Line ,� g I 47/ SEEPAGE PITS I 1 Depth Size _ Number SUMPS LI 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 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 compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow : "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 Ea vs of Cal' r�a." The.applican us call for all re uired inspections. Complete drawing on rev a side. Signed X Title: 1 D e: FOR DEPARTMENT USE ONLY ppticagoq Accepted by Da ! -� hr�(� Area 1 u-r Y" - — 3 Date Final In actio/p by /a ate Additional Comments: �� df�7?. fes/ a•`/r'•�l!/�(t� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca U3-7104 ❑ Tracy 835-6385 LOA Appilcant - Return all copies - Vito an I Health rmit/Services 1601 E. He he" a., P. B�20 Stk., CA 95201�kH � FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH i +.EH 13-21(REV.1/K 5) ®• 9 �� n/t (� U EH 11-26 v (r � `] VX i