89-1486 - Laserfiche WebLink

Home Browse Search

S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L '' 1601 E. HAZELTON AVE., STOCKTON, CA Telophone (209) 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, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Olstnct ��,x'7 �� ,,�- �.�; ;Ya *�r"�� Job� 41 Adtlress �- City at Size_ PM r I Owner's Name1? *Aet Addresses Phone Contractor Address `cense No.�Phone_ - TYPE OF WELL/PUMP: V ' NEW WELL ❑ WELL REPI ACEMENT �' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK !?( /ig SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION.. - - AGRICULTURE.WELL�-.- — OTHER WELL-67C—Z ' PATS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y i Dia. of Well Casing X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing 1"fr',_i Specifications , t`1 Public f7 Other Cl Delta Depth of Grout Seal � !/t Type of Grout Z1, I I I.Irrigation il/�+-Approx. Depth f 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Seating Material {top 50'i ., Depth i Filler Material (Below 501 CZY TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l_I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.? Installation will serve: Residence— Commercial_ Other + Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest; Well Foundation 'Property Line I I � i F LEACHING LINE . ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I l SEEPAGE PITS F I Depth Size — Number SUMPS Cl� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � 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. 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 I 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 Cali ornia." The applidan st call for all required�i`rybpections. Complete rang o r ve se std . Signed X //��7� le: Date: EPA ENT USE ONLY Application Accepted by Data �+_4�_1•17 'L— Area I Pit o Grout sppe�ec^^tti�ion by At Dat Final Inspection by Date--- Additional Coma is �11i 2- ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823- Trag 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Q Q o FEE AMOUNT DUE AMOU REMITTED REC IVED BY DATE PERMIT'NO. INFO CASH +.EH13-241REV.I m51 70- v CH EH 14-28 -70 . 0 0 �� / 7 r ✓.