89-406 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S f r1 ` W.✓• 1601 E. HAZELTON AVE., STOCKTON, CA ! [� V (0 $ 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. Job Address i I City �� Lot Size 0 0-LA40 PM Owner's Name L ii.? J t LL Address rLJ 'V I Phone V L` Contractor `' Address - License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrials- • ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing u Elf]omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r7 hblic-� f Other ❑ Delta Depth of Grout Seal Type of Grout -_ I i Irrigation __--Approx.-Depth I ]`Eastern Surface Seal-installed by _ Repair Work Done ❑ —Type of Pump H.P. State Work Done _ Well Destruction- ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is �`�fff( available within 200 feet.) L v Installation.will serve: Residence Commercial—, Other Number of living units: Number of bedrooms Character of soil to a depth'of 3 feet: latunt"& Water table depth SEPTIC TANK '❑ Type/Mfg opacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ �- / ( p Distance to nearest: 'Well Foundation �. Property Line! LEACHING LINE. 0' No. & Length of lines + Total length/size FILTER BED^ ❑ Distance to nearest: Well Found tion Property Line SEEPAGE PITS L_Depth Size tuber SUMPS /stance to nearest: . Well. Foundatio - Property Line DISPOSAL PONDS_ ❑ I hereby certify that I have prepaied 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 Diltrict. 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." j j The applicant `m call for rrlalll required iAspections.. Complete drawing on reverse side. Signed X t � [IVL �.�.C_� Title: Dater FOR DEPARTMENT USE ONLY Applic 'on Accepted by '�`"'�+ Date ' Area 63'Grour� ion by D��Gate� Final Inspection by� ' Date �Pff r� t Additional Comments: ❑ 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 INFO s��A''�'ttM}ODUNT DUE A�MyOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. ..FH t3241REV.1/85Y j V Xf �/ X a EH 1426 +�Z !/ V