89-3063 - Laserfiche WebLink

Home Browse Search

p F i` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r r kPERMIT EXPIRES TYEAR FROM DATE ISSUED h (Complete in Triplicate) i 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 i Local Health District. ! r I fJob Address �J _ City Lot Size PM ii Owner's Name ._-___. � f-Address iT>I ., Phone Contractor res, 1l cense No.4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE h 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 t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other f7 Delta Depth of Grout Seat Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is y� t available within 200 feet-) v l Installation will serve: Residence'_Commercial Other Number of living units: + ' Number of bedrooms Character of soil to a depth of 3 feet: t ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG.TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation P�operfy Line 4 I LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth- iz /Number SUMPS Ll Distance to nearest: Well Foundation 3�J Property Line Ifb SPOSAL PONDS ❑ i. 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 District. f k 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,./ 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 parsons subject to workman's compensa- tion laws of California." ij The applicant t r&Lfequi pections. Com�11118r ing on reverse side. G' Signed X Title: Date: f k FOR DEPARTMENT USE ONLY h Application Accepted by bate Area 21 1 Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: f! Stk 466-6781' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 9 INFO CASH RECEIVED BY DATE PERMIT ND. ♦ EH 13-24(REV.t/H 5) EH 14-26 L7 �f