89-2687 - Laserfiche WebLink

Home Browse Search

+ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. I Job Address 1583 ..4. &,4Z -- 4-A-4JCity Lot Size ZledG PM Owner's Name /q NGE LB� i.",G/NErJAddress f5' 9� Af. Gc.l,4 Phone Contractor 4 D _Addre_ss 7 X1 License No, ZA-X-S'�2-7L Phone S'37 TYPE OF WELL/PUMP---- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i` INTENDED USE ,k TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial y ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Packi ❑ Tracy Type of Casing Specifications F] Public ❑ Other {� ID Delta Depth of Grout Seal Type of Grout _ I I Irrigation A g' _. pprox. Depth I ] Eastern Surface Seal Installed by {,v r Repair Work Done ❑ Type of Pump H.P. State Work Dane_ "1 Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ G TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION- --DESTRUCTION € I (No septic system permitted if public sewer is "J - 1. available within 200 feet.) Installation will serve: Residence---,.;/Commercial_ Other s i Numbereof_living-units:-- Number of bedrooms Character of soil to a depth of 3 feet: 4 L-,4 y ; - r ._ Water table depth SEPTIC TANK � - .t ❑ Type/Mfg Capacity No. Compartments PKG..TREATMENT PLT. ❑ 41f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE GeIN.. & Length of lines /- O ` Total length/siie 14'47 -'A Z z FILTER BED ❑ Distance to nearest: Well Foundation /.S Property Line _.._ t f 4 r SEEPAGE PITS l / Depth S r Size 3 +r Number SUMPS ❑ Distance to nearest: Well SGO r Foundation Property Line 2-6/ r DISPOSAL PONDS Cl f r 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 HealtWDRitrict. i' _ Home owner or licensed agent's signature certifies the following: "I certify i6at in the porformance.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." I The applicant must call for all required inspections. Complete drawing on reverse's,ide. f ' 14 Signed X �- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection byDate z Final Inspection by--5, ��° Date �7 Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 935-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. +.EH 13-21(REV.t i x 5) K. EH UI-28 i