89-731 - Laserfiche WebLink

Home Browse Search

u APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telepho'n'e (209) 466-6781 PERMIT EXPIRES 7'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. � 'n., I" Job Address 30� City Lot Size PM Owner's Name6- L _ Address S4 $; �`OA1?sr1��( S7iC�,t1S— / Phone Contractor I ---r----�+—��?-7 Address Z_ zt/r �+>a.� s �—�— License No. TYPE OF WELL/PUMP: NEW WELL ❑ - ��s•z�� Phone_ X5-39'7 WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC.TANK OTHER ElSEWER LINES �_�� DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. - ' b,... ❑•Man Dia. of Well,Excavation ❑ Domestic/Private ❑ Gravel Pack u Dia. of Well Casing racy Type of Casing i"1 Public ❑ Otherf 1 Delta Specifications I I Irrigation epth of Grout Seal Type of Grout --Approx epth ( I Eastern Su ce Seal Installed by Repair Work Done ❑ Type ump H.P. State Work Done_ Well Destruction ❑ ell Diameters ��' ,t Sealing Material (top 50') ' t 4 Depth _ ff TYPE OF SEPTIC WORK: NEW i z W Filler Material (Below 501) INSTALLATION i 1 Ir-r-I AMN/AUDI 1,110NX DESTRUCI1pN I I INo septic system permitted it public sewer is C Installation will serve: Residence�_ available within 200 feet.) ommercial Other Number of living units: _L Number of bedrooms Character of soil to a depth of 3 feet: � L SEPTIC TANK ❑ Type/Mfg Water table depth`- PKG. TREATMENT PLT, ❑ .,,, ,�r-- ^--t � i Capacity No. Compartments f � T " ^� �— Method of Disposal Distance to nearest:' Well =1 Foundation ' q:,' 'i i� x Property-Line Z. LEACHING LINEI "* r Y.. &.Length of lines. � FILTER BED + Total length/size ❑ Distance to nearest: Well Foundation I Property Line 1 17 SEEPAGE PITS I I Deoih Size z SUMPS —� — Number L� Distance to nearest: Well •N r Foundation _ Property Line DISPOSAL PONDS Q �' `+,� r 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 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 Jaws 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 tion laws of California." t.. , f persons subject to workman's compensa- The applicant must call for all irequired inspections. Complete drawing on reverse side. Signed >' , � Titley. - Date: & , F FOR DEPARTMENT USE ONLY Application Accepted by 1 Date / ~' Area :�o Grout Inspection by - e � Final Inspection by AA date .3 fir! itiofn'ments: ❑ Stk, .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 ' Applicant- Return all copies-to:.Environmental HedItj1,Permit/Services 1601 E. Hazelton Ave., P.O, Box 20%,�Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. r EH 1324(REV,t EH 14.29 9,9-7.3