89-155 - Laserfiche WebLink

Home Browse Search

" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Id 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (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 Local Health District. 1 i1__ City Lot Size AflZ ZO PM Job Address +� Phone Owner's Name Address Contractor/ Address License'No,.2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - q DISTANCE TO NE : SEPTIC TANK = SEW ER�LINES DISPOSALFLD SAP--. LINE k FO ION AGRICULTU OTHER WELL PITSlSUMPS (� INTENDED USE TYPE OF WEL LEM AREA CONSTRUCTION SPECIFICATIONS Dia.�. of Well Casing ❑ Industrial ❑ ottom ❑-Mantec Dia. of Well Excavation ecificatson s f_1 Domestic/Priva CI Gravel Pack ❑ Tracy y Casing p f'1 Public 17 Other F1 Delta Depth of Gro l Type of Grout _ I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r. Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIRIADDITION E I DFSTRUCTIO l (No septic system permitted if public sewer is able within 200 feet.) �. Installation will serve: Residence— Commercial— Other avai 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 Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS I I Depth Size Number t SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .�1 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 tollowing: "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 applicant must call for all re fired ins tions. Complete drawing on reverse side � '� Y_ Signed X �'/• Title: (��ae�fa/- A- tet Date: FOR DEPARTMENT USE ONLY I Date L11 Area t Application Accepted byo� �� Pit or Grout Inspection Date Final Inspection by Data Additional Comments: a ❑ 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, Stk., CA 95201 eCKVr FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. f INFO +.EH 13-24{REV.I/H 5153 l EH 14-26