89-167 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT L_SAN_J.OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA WT q Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 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. Job Address City Lot Size PM Owner's Name C� 17 GSM1� Address � Phone —Contra(to RAddress ._C7_ _ License No..'t'7701 Phone TYPE OF WELL/PUM - NEW WELL WELL REPLACFMENT ❑. DESTRUCTION LI SYSTfM REPAIA 171' _. _ _ rOTHER �l_ ,. 9,_x.1 DISTANCE TO NEAREST: SEPTIC TANK C�01SEWER LINES __'%4V9 A ; D15POSAL FLD,'20a'` PROP. LINE __ ,FOUNDATION AGRICULTURE WELL OTHER WELL -,,PITS/SUMPS INTENDED USE TYPE,.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSJ. 7 i/ ❑- Industrial pen Bottom El Manteca Dia. of Well Excavation ia. of Well Casing ltd-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 7 _ pecifications 1-1 Public n Other L1 Delta Depth of Grout Seal ` -Type of Grout I rigation _Approx. Depth I I Eastern ' .surface Seal Installed by + _ Repair Work Done ❑ Type of Pump H.P, State Work Done Weil Destruction ❑ Well Diameter _ Sealing Material flop 50'1 s �} Depth < Filler Material 18eldw 50'1 } b TYPE OF SEPTIC WORK: NEW IASTALLATiON E 1 REPAIR/ADDITION I DESTRUCTION i I (fVo septic system permitted if public sewer is T available within 200 feet.) fl Installation will serve: Residence_:Comrne`rcal Other t r Number of living units: Number df-bedio` tris', Character of soil to a depth of 3 feet: # 1 RJ -< +'' ) Water table depth T SEPTIC TANK ❑ Type/Mfg 5+ Capacity No. Compartments PKG_ TREATMENT PLT. 171 ': }`` , r .; '; 4�. rY Method of Disposal t Distance to nearest: Well Foundation Property Line - t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t 4 - SEEPAGE PITS I I Depth Size Number i y SUMPS.; P Distance to nearest: Well' �''F'06ndation Property Line EIDISPOSAL PONDS j 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 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit;is issued,I shall employ persons subject to;worl man's compensa- tion-laws of California." _ The applican m call fpr IIold lspeF ions. Complete drawing on r rse.sc e. gy t �� ----- $i ned - Title: Date: +3 r FOR DEPARTMENT USE ONLY q Application Accepted by }� Date L Area Pit or Grout Inspection by Date ' f11� Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_, P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH 13-2;tREV. /F311 S ! EH 14-28. / 1