89-2468 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (269) 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 wel$/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O Cit Lot Size PM Owner's Name Address `� . 9 Phone r 77 Ph3&� S1 Contra ress '� License Pyo. Z one_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES .DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL`- , OTHER WELL PITS/SUMPS _- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil'Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifi1;ians l`I Public (_! Other ❑ Delta Depth of Grout Seal Type of.Grout - °`- I I Irrigation _--Approx. Depth I I Eastern Surface Seal Installed by d Repair Work Done 0 Type of Pump H.P. � State Work Done Well Destruction t] Well Diameter Sealing Material (top 501 Depth T Filler - (Below 50') TYPE OF SEPTIC WORK: NEW INSTAL ION 11 REPAI /ADDITIO DESTRUCTION Mo septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence Commercial-.— Other-- Number ther Number of living units: _/_ Number of be rooms .�j Character of soil to a depth of 3 feet: Water table depth Cm• 'SEPTIC:TANK, f .5 Type/Mfg. f Capacity No. Compartments �1 PKG. TREATMENT PLT. ❑ el I ! ! Method of Disposal Distance to nearest: Well Foundation $ 5� __. Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _"FILTER BEDf�'�-f' `Q ''Disfance to'nearest:. Well- Foundation Property Line ' F SEEPAGE PITS I 1 Depth ' Size! _ Number SUMPS 0Distance to nearest:" Well ' "" "" "Foundation Property Line DISPOSAL PONDS' 0 Lhereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a rules and regulations of the'San-Joaquin Local Health Di§trict. i 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-mannerras 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." n The applican ust call for 11 re ui inspections. Complete drawing on reverse std . p Signed X Title: Date: 412:� FOR DEPARTMENT USE ONLY, Application Accepted byl �mm�cc-, .� Date,-& Area Z Pit or Grout Inspection by Date Final Inspection by h Date - 2� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L1 Manteca 823-7104 J R0 Tracy 635=6365'' - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT�NO. + EH 13-24(REV.I/n5) �e) C—Ac EK 14-26