89-1652 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 / 'l / tJ t/ d+ City Lot Size J /"T Ke=5- PM Owner's Name � r f(�J/�f 7)� Address � 71 M4 L6 woo Phone Contractor Address asD License N0.43t);&3,�-Phone X ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private LJ Gravel Pack 171 Tracy Type of Casing Specifications I'] Public F1 Other F1 Delta Depth of Grout Seal I i r Type of Grout r i ♦ fl I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ .....,_.mer Well Destruction ❑ Well Diameter ' Sealing Material Itop 50'1 Depth T ""-'" Filler Material-IBelbw50'1`� * f — _ .,� _ P YJyTYPE OF SEPTIC WORK: NEW INSTALLATION i47--R'EPAIR/ADDITION 1 1 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence tY ommercial Other EE Number of living units: J Number of bedrooms __!�o I �' Character of soil to a depth of 3 feet: CWater table depth SEPTIC TANK ❑ Type/Mfg` Capacity aQa No. Compartments �+ PKG. TREATMENT PLT. ❑ � Method of Disposal G Distance to nearest: .Well Foundation,—' / Property Line t LEACHING LINE Length of lines 'T Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS V/lYlepth T Sizeu Number 6(2 SUMPS ❑ Distance to nearest: Well Foundation 4 0 Property Line DISPOSAL PONDS- V ,❑ ? 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. 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 signat certif' 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 Californi ' The ap lican t all for 11 re uire nspec i mplete drawing on reverse ide. ell Signed Title: Date: 7 `/�// E FOR DEPARTMENT USE ONLY Application Accepted by —7--.A 40,/, Date Area 12— Pit or Grout Inspection by ate Final Inspection by__ �� Datel,�� Additional Comments: e ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 "-FEE —AMOUNT DUE - ANIQUN7 REMITTED"" "�K "' I" RECEIVt D BY `"��" � DATE '^ PERMIT'NO.. INFO CASH Ih +.EH 13-24 iREV.1/n 51 —7Q EH 14-28 -