89-78 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. r i Job Address City Lot Size PM Owner's Name Address & Phone i C- Contractor �'J Address d J License No Phan F . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ x.. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL"'--'OTHER WELL PITSISUMPS iWENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C1Open Bottom _ -© Manteca - Dia. of Well-Excavation' Dia. of Well Casing ""Y + D Domestic/Private ❑ Gravel Pack 1-1Tracy ` Y Type of Casing " " Specifications F] Public ❑ Other if Cl Delta Depth of Grout Seal Type of Grout ---- I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by - - + Repair Work Donee ❑ Type-of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth t ___Filler Material (Below 501. - TYPE OF SEPTIC WORK: NEW INSTALLATION I RE.f AIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within•200 feet.) Installation will serve: Residence--.Commercial Other Number of living units: Number of bedrooms -e Character of soil to a depth of 3 feet:' #_,. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity . Nei. Compartments PKG. TREATMENT PLT- ❑ ; F Method of Disposal Distance to nearest: Well Foundation P�operty Line LEACHING LINE No. & Length of lines Total'lengthisizee FILTER BED ❑ Distance to nearest: Weil Q ____Fountjation_ �40�, Property Line SEEPAGE PITS I I Depth 'Size " Number = SUMPS L) Distance,to nearest: Well'- Foundation a -:__.:J-Pr perty Line DISPOSALRONDS ❑ 1 -} I hereby certify that 1-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 District. r , Home owner or licensed ag is signature certifies the fallowing: "I certify that in the performande of the work for which this permit is issued, I shall not employ any person in sue nner as to become subject to workman's compensation laws of California."Contractor's hirin or sub-contracting signature certifies the following: " ertify that in the performance of the wo r,which this permit is issued,"l shall employ-per su act to workman's compensa tion laws of Californ- The applic t u call for squired i ing o erso sicl 1 Signed e: Date: i FOR DEPARTMENT USE ONLY i VIApplication Accepted by Date �-. Area Pit or Grout Inspection by ' Data Final Inspection by"� Date! f Additional Comments: xY EJ Stk 466-6781 ' ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 - f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 "+4 FEE AMOUNT DUE AMOUNT REMIT-TEDCASH CK RECEIVED BY DATE PERMIT NO. INFO GG Q +. EK 13-24 1 pEV.I/H 55 79 FH 14-28