89-1444 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k - 1601 E. HAZELTON AVE., STOCKTON, CAG T a U i Telephof)e (209) A6&#Wr7 D 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �, ✓!z `�fGlct/ Cit Y 616w--w° Lot Size PM Owner's Name �- oZi,61© �"�sT L,/� Address � Phone/ ��`,6��S�'3 Contractor Address�6I� honef 7k,6-F6 3 ��"/�= �i� License No.-! PI TYPE OF WELL/.F'UMP:__ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 - PUMP -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ~ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � 1 FOUNDATION ' .AGRICULTURE.WELL_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia- of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`i Public F) Other n Delta Depth of Grout Seal I I Irrigation ._Approx. Depth 1 I Eastern Surface Seal Installed by Type of Grout W Repair Work Done ❑ Type of Pump H.P. ` s State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ( I DESTRUCTIO INo septic system permitted if public seJis -available within 200 feet.) Installation will serve: Residence_ Commercial_._ Other Number of living units: Number of bedrooms 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S SEEPAGE PITS I I Depth Size , Number 1 SUMPS L7 Distance to nearest: Well Foundation Property Line r 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 rules and regulations of the San Joaquin Local Health Di$trict. Home ownevor 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 subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: '9 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 Calif rnia." The applican m t I o uired inspections. Complete drawing on reverse side. Signed Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date _ `'r ► Area 6 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED INFO CKSH RECEIVED BYE ATEPERMIT'NO, EH 13-24 IREV.t/ �EH 11-29 �'�(J a /