89-306 - 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 iCornplete 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. t, Job Address f7 e r' r ] -- City S 1 Lot Size PM Owner's Name G-e-om& e Address �� lU! 4f «-f- A r1 yeki �fM�we C Contractor 14_�� [1 'l - Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. ❑ y DESTRUCTION ❑ PUMP INSTALLATION © - --wSYSTEM REPAIR OTHER,❑, ,_: DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM"AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private-, ❑ Gravel Pack ❑ Tracy,_ Type of Casing Specifications F] Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout Ixi-Irrigation- =.-Approx, Depth t I Eastern Surface Seal Installed by _ (N Repair Work Done ❑ Type of Pump H.P. State Work'Done T Well Destruction ❑ Well Diameter Sealing Material atop 50'1. t Depth _ Filler Material IBeI 1 TYPE OF SEPTIC.WORK: NEW INSTTION 1.1 REPAIR/ADDITION rl DESTRUCTION l I (No septic system permitted if public sewer is ✓/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other li Number of living units: —�— Number of be rooms C- Character of soil to a depth of 3 feet: n Water table depth± SEPTIC TANK x ❑ Type/Mfg's Lam{ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line II V?-0'N,1 f LEACHING LINE fie?/No. & Length of lines Total length/size IZO FILTER BED ❑ Distance to nearest: Well 0r Foundation { P- ..- Property tine q�- f SEEPAGE PITS Depth ' ra Size Number }� mm SUMPS Distance to nearest: Wellf Foundation� Property Line _ F DISPOSAL PONDS ' I 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 i rules and regulations of the San Joaquin Local Health Di>;trict. 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,1 shall employ persons subject to workman's compensa='s .. tion'1aws of California." The applicant must tail for"reqed inspections. Complete drawing on reverse side. i ��-�itti j- Signed7iNe:. ` Date: i FOR DEPARTMENT USE-ONLY Application-Accepted by Date /—;z ( . Area - '•`ate "" � . -Pit or.Grout Inspection.by_- -Date '-• t.Final Inspection by Date 1� Additional Comments: ❑ Stk466-6781 . ❑ 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 c FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT•NO. 00 +.EH 1324(REV.1 x 51 f EH 14-26 ® r L / CS