89-763 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,-TON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) quin Local Health District for a permit to construct and/or install the work herein described. This applicatio Application is he+eby made to the San Joan is made in compliance with San Joaquin County Ordinance No.549 for sewage yr No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. J _ City Lot Size PM Jab Address 1 Cen( t"2 Address �``�` ` f' Phone Owner's Na 1 } r" -O� � Phone Cpntractor {/ f it Address [ License No. NEW WELL ❑ WELL REPLACEM NI ❑ DESTR TYPE OF WELL/PUMP: UCTION L1 PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER 11 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 pia. of Well Casing C1 Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private El Gravel Pack C1 Tracy Type of Grout - n Public [7 Other ❑ Delta Depth of Grout Seal I 1 Irrigation —.-Approx. Depth l I.Eastern Surface Seal Installed by Hy. State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material itop 50') Depth Filler Material (Below 501) n� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION available tic w thin 200 feet+t�ed if public sewer is lW Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms_- -- / Nater table depth Character of soil to a depth of 3 feet: 4 SEPTIC TANK ❑ Type/Mfg Capacity ( - No. Compartments f PKG. TREATMENT PLT. ❑ - ' Method of Disposal': '4 Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size r ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I i Depth Size — Number SUMPS 0 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.. "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's shinoru -conmantincompensa- ur certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ psubject tion laws of California." The applicant must call for all requir pection . Complete drawing on reverse side. }�� d e Date: Signe I / R DEPARTMENT USE ONLY / A� Date % a r! Area Application Accepted by Pit or Grout Inspection by z to Final inspection by _ Date ` Additional Comments: P El Stk 4&6-8781 fl Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH INFO EH 13-24+REV.i/K51 r EH 14-2e