89-1468 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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 1- made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin Local Health District. /q j FJob Addre Owner's Name ss ' ` city s "' �" Lot Size PM ` Lm�f Com... Address �' C ¢— � - Phone ' r` Contractor Address 5.,3o Aj o'tit License No. Phone ~ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION d SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yam. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private.,.,,,., ❑ Gravel Pack R ❑_Tracy Type of Casing � Specifications [-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation" —.-Approx. Depth I 1 Eastern Surface Seal Installed by - f Repair Work Done ❑ Type of Pump H.P. State Work Done_ UJ V� i Well Destruction ❑ Well Diameter Sealing Materia! Stop 50'1 -� Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other M' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth (� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ` Property Line LEACHING LINE ❑ No. A Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'] Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 aw (tensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not em any person such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature rtifies 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 Californi µ The applicant must all r a I req ire ins ctions. Complete drawing on reverse side. ' , ?�-( Dater Sign ile: _ FOR DEPARTMENT USE ONLY Y. Applicatio Accepted by Date `Area Pit or Grout Inspection by Dat Final Inspection byf Date 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. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. INFO f g/ y /_ � +.EH13241AEV.I;As) �_, � � 3� "� lZa �` lQ"Zw� - I EH 14-29