90-1386 - Laserfiche WebLink

Home Browse Search

.. t: r . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES TYEAR FROM DATE ISSUED MAY 2 9 1989 r. (Complete in Triplicate) SAID JOAQUIN COUNTY � {� FETN SERVICES jnA�r �IQ (�( lication is Application is hereby made to the San Joaquin total Health District far a permit to construct and/or p s and a ulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18fi2 for well/pump g Local Health District. M' City Lot Size C PM " Job Address <°'�`' III q A+ Phone Owner's Name 0ti'� Address ,/� / II 4r`�License No. Phone Contractor.' L..�°"'t�e Address TYPE OF WELL/PUMP: I� NEW WELL '"W,2_ WELL REPLACEMERT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ S� I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �® ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -Qia. of Well Casing ❑ DomesticlPriva El GFave1 Pack ❑ Tracy Type of.Casing Specifications F'] Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation I I�Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P, State Work Done Well Destruction ❑ Weill Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is ,I`. available within 200 feet.I [ _ Installation will serve: Residence_ Commercial— Other V� Number of living units: Number of bedrooms Water table depth 1, Character of soil to a depth of 3 feet: �\ SEPTIC TANK ❑ TypelMfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line I �I � LEACHING LINE ❑ Total lenthlsizeNa. & Length of lines g FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth Size Number --- SUMPS Cl `Distance to nearest: Wel 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 Di?;trict. 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1 The applicant must call for all!required ins q!2 omplem drawing on reverse side. Signed X Title: _ Date: 2� �y FOR DEPARTMENT USE ONLY Application Accepted by !. Date Area 7 >`2."7L� � Date U�-�� � Date� Final Inspection by Pit ar rout•'nspection by ��' `"�� / " Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 l ❑ Tracy _935-6385 Applicant- Return all copies fo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH13.24(REV.1185) � . 1 d 'J0-4_� ' EH 14-28 .III