89-2517 - Laserfiche WebLink

Home Browse Search

4' APPLiCAT1bN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA G i Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED irrl.li;A�i"' (Complete in Triplicate) PER A!TISFRVIC R" 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 i 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 City Lot Size PM Owner's NamemA AddressPho j/2^i_ f n��7 Contractor C Al WIDOW&=Address,119S nse N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 75, DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKOLS "' -` SEWER LINES DISPOSAL FLDA22:�67pROP. LlNG..�� FOUNDATION 199 AGRICULTURE WELL OTHER WELL PITS/SUMPS �— € - INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "`!'c"- '❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T Dia. of Well Casing '; DomesticlPrivate, Gravel PackTraCCasing Y Type of Casin ecifications I'll Public v� g ❑ Other F1Delta Depth of Grout Seal I i Irrigatipn� q Type of Grout �J�V pprox. Depth I 1 Eastern Surface Seal Installed by f - Repair Work Done ❑ Type of Pump H p _ Well Destruction EJ Well Diameter State Work Done_ Searing Material (top 50') ! .. Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is n ^' Installation will serve: Residence» Commercial Other available within 200 feet.) Number of living units: Number of bedrooms 1 t Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg PKC. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal Property Li Distance to nearest: Well Foundation _ r -•� no LEACHING LINE ❑ No. & Length of lines �1 + r '.Total length/size < FILTER BED ❑ Distance to nearest: Wellj Foundation Property Line SEEPAGE PITS I I Depth s Size SUMPSLI Di — Number Distance to nearest: Weil Foundation DISPOSAL PONDS " y— _ Property Line 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 DiMrict. 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 notCi- employ any person in such manner as to become;subiect to workman's compensation laws of California.•• Contractor's hiring or sub-contracting signature certifies the following: "I c rtify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The app' t us 11 r all re .,J„_._ " s ed ins ns. Complete drawin2� g on re Ise side. t Signed Title: Date: FOR DEPARTMENT USE P Application Accepted by Date Area / Pit or Grout Inspection by bate Final nspecti n by Date Additional Comments: / .c 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 `` + Applicant- Return all copies to: Environmental Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201/"? r FEE INFO NT DUE i AMOUNT REMITTED CK `�7 CASH RECEIVED BY DATE PERMIT'No. .-EH 13-24ir1EV.iiH51 ! 0. oo n I_ 1 EH 14-28 t li�'1. i o`/f P��Z.S 7 ' f