89-1332 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT tJ�t SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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. 9�+9� i'�llE� i city �'UDJ- Lot siZe�� ac PM ' Job Address JEFF 1-Mi NDEx;_S O NSA�. Phone i Owner's Name Address r� ITH GK(7SS Address Py BOX 178 License No. �77�`35 Phone � '-�+7 5 Contractor f ;r WELL REPLACEMENT ❑ DESTRUCTION ❑ f TYPE OF WELL/PUMP: NEW WELL 1 SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION Q"�'� � 2,D fG2t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. POOP. LINE FOUNDATION._ AGRICULTUREWELL_ OTHER WELL PITSISUMPS 14 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7' ' ❑ Oen Bottom ❑ Manteca Dia. of-Well Excavation I �ZCI7 Dia. of WeIICasirig' �' �- O © Industrial P BS](t, Specifications' ' Type of Casing 4:1 Domestic/Private �;�1•Gravel Pack ❑ Tracy _��Q �- "' —Ty Gror�t'�O'�� { f`1 Public J L1 Other Li Delta Depth of Grout Seal ` GOA-L�"�G:�{1 :I I I Irrigation 220..Approx. DepthS.UB i 1 Eastern Surface Seal Installed by actor H.P. _ / C Oi1 �' ' State Work Done Repair_Work Done C7 Type of Pump 1f - _�2 Well Destruction ❑ Well Diameter Sealing Material (top 50') �' ;Depth Filler Material (Below 50'1 I system pbrm TYPE OF SEPTIC WORK: NEW INSTALLATION,IJ-HEPAIR/ADDITION I ! DESTRUCTION i 1 available(Nolwthin 200 feet"Ied if public sewer is l Installation will serve: Residence— Commercial_ Other f ' �. Number of living units Number of�bedrooms i . '-Water-table-depth Character of soil to a depth of 3 feet: 1; SEPTIC TANK ❑ Type/Mfg Capacity� � " No. Compartments Method of Disposal ,PKG. TREATMENT PLT. ❑ l y Distance to nearest: Well Foundation Prerty Line Y , LEACHING LINE LI No. &Length of lines Total length/'size FILTER SED ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size _ Number SUMPS L7. Distance to nearest: Well Foundation \Property Line\ r DISPOSAL PONDS ©' I hereby certify that I have ptepared this application and that the work will be done in accordance with San Joaquin county ordinances, �ate laws, and rules and regulations of the San Joaquin Local Health District. 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." The applicant must Il for all required inspections. Complete drawing on reverse side. Signed X Title: Date: OVT'ld.Ei � �-`.��-�� 9 � FOR DEPARTMENT USE ONLY Date` r_ '..Area L= r Applica.Ai n Accepted by J fE t t � to �_ / Final Inspection by� �� Die Pita Grou Inspection by ✓ f Addi " I Comments: C3Stk 466-67p1 ❑ 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 95201`% r FEE CK RECEIVED-BY_..-. -DATE -PERMIT,NO.-T.•_��.,- AMOUNT SUE ,�. . .AMOUNT REMITTED.._. . .-CASH -INFO _ ♦.EH 13-24(REV.t/n sl EH 14-26