89-1133 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT r SAN JIO_AQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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 worts herein described. This application is made in compliance with San Joaquin Co6ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I1 rJob Address City��r^�C_ie–b ot Size PM G C Y II AA ii War, ,�1 [ r� /v3� 7 -7 Owner's NameA. Address w L [� 1/V e- , � Phone `if�alS 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 FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARkA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing I Specifications 4 f"1 Public Cl Other 'f I t Cl Delta � Depth of Grout Seal Type of Grout _ Q� I I I Irrigation _..Approx'. Depth I I Eastern Surface Seal'InstaEled by Repair Work Done Ll Type Type of PumH.P.. ''_ ;` State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I Filler. Material (Below 50') ~ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION i I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms 1 { ' Character of soil to a depth of 3 feet: ' J j Water table depth l SEPTIC TANK ❑ Type/Mfg/ k Capacity No. Compartments �l PKG. TREATMENT PLT. ❑ Method of Disposal 111 4 Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well- Foundation Property Line SEEPAGE PITS i I Depth I Size Number D SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di%trict. 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." f The applicant call for ail required in ctions. Complete drawing on reverse side. Cho Signed X Title: Date: Application Accepted by FOR DEPARTMENT USE ONLY Date r,..��,��_ p�L,-±Q Area 1 1 l s�sY lilt-r. C boll Pit or Grout Inspection by Date Final Inspec on y pate a�v S��•e -{�/�a`�' c s Additional Commenm rr ,� 0 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 955201 FEE INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. j + EH 124(REV.r/n 57 �� UI /� 1 1.1 � ln� fm 19 EH 11-4-28 [ aJ �7` ` I