89-2725 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED l i (Complete in Triplicate) Application is hereby made to theiSan Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in com6liance 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. I Job Address I S City Lot Size PM �, d 1".In 0 d� Address Phone Owner's Name -- .. Contractor— �' Address f Y �+ License lVo. � �r�Phone r' ^ contractor TYPE OF WELL/PUMP: I� NEW WELL C] "WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public 17 Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation --..Approx. Depth l 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 F' Dept liM Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if puhlic-sewer is y , / available.within 200 feet.) Installation will serve: Residen`ce V Commercial_ Other C Number of living units. ��' Number of bedrooms Character of soil to a depth of'3'feet: a Water table depth SEPTIC TANK Type/Mfg _ .oL- L, Gnr1r_Cr,. -E.' Capacity_ Q=+ No. Compartments r PKG. TREATMENT PLT- ❑ II ' t r Method of Dspsal. Distance to nearest: Well Foundation - Property Line DIST LEACHING LINE / II {ILf No. & Length of lines Total length/size d d I FILTER BED El 1)stance'to'nearest: Well Foundation �' Property Line SEEPAGE PITS II Depth Size__-_—�Y r�^+� Number SUMPS Iy1�Distance to nearest: Well / ,�,,� / ''Foundati n � �Y "Property Line fes] DISPOSAL PONDS ❑ -6� i I hereby certify that I have prepared this application and that the work wiA,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: "1 certify that in the performance of the work for which this permit is issued, I shall not t 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 California." 'I�i The applicant must call for all req ed inspections. Complete drawing on reverse side. R. Signed X Title: � _q A,V1 J_ Date: FOR-f)FPARTMENT USE ONLY �F Application Accepted by W �,J Date = w �'A ed Pit or Grout Inspection by I� Date Final Inspection by Date If , t/If Additional Comments: II� k ❑ Stk 466-6781 ❑ Lodi ill 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13-24(REV.tin5) EH.14-29