89-222 - 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) 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 L al Health District. t�r cuJiJCY - —'��pr a/� gP�1 O YO-/z X9,4--��o ^� /. ob Address Si L: w f �/g City Lot Size PM Owner's Name 4<A L/ Address Phone. Contrac#tor�All 1�-� Address " " License No ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FCD. PROP. LINE j i FOUNDATION _AGAIC,ULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I ❑ Industrial -❑ Open Bottom ❑ Manteca pia. of Well Excavation +- Dia. of Well Casino + C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V - I I Irrigation - .Approx. Depth l I Eastern Surface Seal Installed by I _ C► Repair VVork Done ❑ Type of Pump H.P. State Work Done_ j Wel! Destruction ❑ Well Diameter _ Sealing_Material_ftop_50'1 J Depth Filler Material (Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t; '-N.DESTRUCTION 11t1Na septic system permitted if public sewer is "! 3 '' j 'available within 200 feet) { f Installation will serve: Residence'Commercial_ Othef _ . ,7 Number of living units: X_ Number of bedrooms Character of soil to a depth of 3 feet: ''-' Water table depth ` P i �. SE TIC TANK .L - - QMH L��A ❑ Type/Mfg l a acct, q No. Compartments } �r� / --. P Y � 1 PKG. TREATMtrNT PLT. ❑ t r ,... � .l � Method of Dispose! Distance to nearest:" Well � 'Foundation Pro ert ;Line LEACHING LINE ,No. & Length of lines ' rte. T Total length size 7— FILTEft`BED ❑ Distance to nearest: Well -Toundation Property Line �cCpl�! r A Fa j I _ SEEPAGE PITS I Deptht A15' Size '( Number SUMPS 0 Oistan,'O" nearest:.-::. Well Foundation Property Line I DISPOSAL PONDS O `-' '. i t I hereby certify that I have prepared this application and that'the' work will Ng done in accordance with San Joaquin county ordinances, state laws,and x rules and regulations of the San Joaquin Local Health Di?;trict Home owner or licensed agent's signature certifies the followirig: "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 wo&fdi which this permit is issued, I shall employ persons subject to workman's compensar ' tion laws of California." _ The applicant must call for requir ins ctions. Complete d awing on"reverse side. s l 4 F Signed'X !�C i,��O�n.1 Title: —ar.a4.".04-", flare: �� .M ' _ FOR DEPARTMENT USE ONLY � r ApplicAon Accepted by 1 Date �w Area ;. Pit or Grout Inspection by � �''•Date 'Final inspection by Date f Additional Comments: < ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 823-7104 a, ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F TFEE NFO- D -AM OUNT' UE—— ^ 'AMOUNT-REMITTED.ter CASH "_ DATE""" '•.T�'RECEIVED'BV " �""" �P€Rhll1T"NO:"" _- EH 14.211