89-2442 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 s 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. - Job Address Zraro s- 'r!_` City Lot Size PM Owner's Name Address _ 7 944dillk Phone Cgniractor Address © t6 tense No.2•nr . Phone r i 'TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ "PUMP INSTALLATION SYSTEM REPAIR .❑ OTHER E) �. . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD.�DA>F PROP. LINEFOUNDATION 6 AGRICULTURE WELL _ -- 0THERWELL�0_ PITS/SUMPS INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' / ❑ Industrial 111,010pen Bottom ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing ' Omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -} Specifications ❑ Public y ❑ Other ❑ Delta Depth of Grout Seal s f Type of Grout `( _. I I Irrigation _..Approx D ;h 1 I �astarn Surfa�a Seal installed by # �'OWA _ Repair Work Done. ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter �Rn't Sealing Materia {top 50') Depth Filler Material (Below 50') 'TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I ] DESTRUCTION i I (No septic system permitted if public sewer is f, available'Within.200 feet.) Installation_will serve:t,Aesidence- Commercial_ Other. 4 Number of living units: Number of bedrooms` Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/.Mfg r s 1' fi Capacity No, Compartments t f PKG. TREATMENT PLT. ❑ ; Method of Disposal t Distance to nearest: ;:Well_ Foundation Prope rty.Line t —^' r ,, .. _ -a. LEACHING-LINE- - - ❑ No:-& LengthwOf lines Total length/size FILTER BED ❑ 1Di is ance to nearest: Well foundation Property.Line f t SEEPAGE PITS I ] Depth Size Number SUMPS ❑ 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. 6 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, 1 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." jThe applicant mu call for all requ' inspections. Complete drawing on r rse side. s ti"Signed X `d - c L Title: Date: FOR DEPARTMENT USE ONLY '@ `Application Acceptedby Date 3 Area Pit or Grout Inspection by -� Date Final Inspection 1 Date 1 =Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63a5 x ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 ` € 3 I FEE .. �; AMOUNT DUE- AMOUNT REMITTED = CK ., .. �R@CEIVED BY- - �� pATE- �- PERMIT NO. INFO CASH +.EH 1324(REV.1/8 5) EH 4-26