89-2652 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) IApplication 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. 1-2 5.q Job Address City Lot Size PM Ir Owner's Name � Q� l�J `T` Address. a h,[� 7 pp�� Contractor �Ukficense No.ZDZ� one `U 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 CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f ❑ Other C1 Delta Depth of Grout Seal Type of Grout I Irrigation .. r- J �..Approx. Depth LI Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Welf Destruction ❑ Well Diameter; :Sealing Material hop 50'I Depth E }Filler !Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is l available within 200 feet.) U y Installation will serve: ResidenceCommercial Other Number of living u its: Number of bedrooms Character of soil o a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity .__ No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal / Distance t j nearest: Well Foundation"Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tc nearest: Well Foundation Property Line a 1 SEEPAGE PITS 1 1 Depth f Size Number SUMPS 1. ❑ .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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. r 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 performan a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor ' a The applicant a I r all quir io m late drawing on reverse Side. Signed X Title: Date: r F ARTMENT USE ONLY k�l Application Accepted nyDate Area `' (f Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: � ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7904 ❑ Tray 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ` ! INFO AMOUNT DUE 4MOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. a.EH 13-21(REV.I/n 51 q EH 11-29