89-2911 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT 1-_JrfS r/A!6- 1-07- D"F SAN JOAQUIN LOCAL HEALTH DISTRICT POCVeD F,R_)OP_ 7-0 '72 1601 E. HAZE 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address 1/-578 S41AI ,E?> cit s7rfC,e7VAI -- Y Lot Size g47,<a-Lf PM Owner's Name Address sX Phone 9.3 3 Contractor F(,&}z _, Lciclaa-7 Address 7 Ao, ZP,5La�-p_7— License No. y7G_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE y. TYPE OF WELL PROBLEM Ak_E4 CONSTRUCTION SPECIFICATIONS N. ❑ lndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing Ell Domestic/Private:. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public I-, n Other 171D'elta., r r Depth of Grout Seal Type of Grout i I Irrigation % --Approx.Depth I i Eastern Surface Seal Installed by Repair Work Done Ell , Type of Pump} H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth '�Fille� Material (Below 50') _ CA TYPE OF SEPTIC WORK:~NEW INSTALLATION ('I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is rF available within 200 feet.) Installation will serve:�"kesidence ✓f Commercial_ Other Number of living units: Number of bedrooms .5- Character of soil to a depth of 3 feet:' I G'GA M Water table depth SEPTIC TANK ❑ Type/Mfg I eG' L r CapacityNo.*Compartments Z_ PKG. TREATMENT PLT. ❑ t Method of Disposal - Distance to nearest: WeII- 75�` Foundation .aa Property Line IX_-r' LEACHING LINE No. & Length of lines S" Total length/size 7 FILTER BED ❑ Distance tc nearest: •Well Foundation 7�z I � _ Property Line �S SEEPAGE PITS I'i—_Depth 'Size 34. ' Number eZ. SUMPS ❑ Distance to nearest: J Well 1'7S Foundation ZAC � Property Line DISPOSAL PONDS ❑ 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 Dr%trict. r Home owner or licensed agent's signature certifies the following: "I eftify-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 corimpansation.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 required inspections. Complete drawing on reverse side. Signed X Title: Date: — OR. D PARTMENT USE ONLY Application Accepted by v Area Date k Pit or Grout Inspection by Date Final Inspection by J Date 7� ) Q 34 ,� Additional Comments: 7 f q/r— El `—❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy,,835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601..E:'Hazeltori Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED` K RECEIVED BY DATE PERMI'r'NO. `�-;,� INFO _ �1�� o Sys 1�5 1a--y-�9 8�-a9 1 +.EH 13-24 4FIEV.,./x 51 EH 1126