89-992 - Laserfiche WebLink

Home Browse Search

y APPLICATAON FbR 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, `} f p Job Address V ^ L, RW IL kd)A City F'1%M109 Lot Size AC- e PM Owner's Name R � _Address Phone eA Contractor j Wk L^ (ed Address l � �t � License No. 2-1111 Phone TYPE OF WELL/PUMP: ri NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ,PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca`4 Dia:oft Well Excavation Dia. of Well Casing t� ❑ Domestic/Private ❑ Gravel Pack ElTracy e41-1 Type of`Casing Specifications M Public 171 Other ❑ Delta ",,Depth of Grout Seal Typerof Grout _ I I Irrigati n --Approx. Depth l 1 Eastern Surface Seal Installed by I Repair,Work Done ter,`❑, Type of Pump H,P, State Work Done Well Destruction '❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other C Number of living units: __LNumber of edrooms Character of soil to a depth of 3 feet: Water table depth rl7 SEPTIC TANK L?-Type/Mfg c tL Capacity 206 No. Compartments a PKG. TREATMENT PLT:❑ N _ t Method of Disysal fDistance'sto nearest;, Well V� Foundation4 Property Line LEACHING LINE No. & Length of lines _ - - + Total length/size' FILTER BED TC] Distance to nearest: Welt�-'` Fo ndation O 'Pro Line SEEPAGE PITS , :;1 I '•Pepth Size °_ Number SUMPS ,fe Distance to nearest: Well tlfl. Foundation Property Line ZDV DISPOSAL PONDS '!6 E] I hereby certify-that I have prepared this application'andihat the work will be done in accordance with San Joaquin county ordinances, state laws, ander rules and regulations of the San Joaquin Local-Health District. i 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 pwformance of the worl�for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.` , _., , ,r The applicant call°for alllepuired in ctions. Complete drawing on reverse side. Signed X �_, TiNei 1�` Date: ss ff R DEPARTMENT USE ONLY_ q Application Accepted by = Date / Area �� v Pit or Grout Inspection by Date Final Inspection by i Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - __turn all copies=to:_Environmental_Health_Permit/-Services 1601_E.,Hazelton-Ave.,-P..O.-Box-2009,Stk,CA-95201 _ FEE AMOUNT DUE AMOUNT REMITTED 4 RECEIVED BY DATE PERMIT NO. INFO --y .. // f + EH112g13-24 IpEV.tiksY / �/SCA I&q —9 q I4