89-1544 - Laserfiche WebLink

Home Browse Search

APPLICATION F"OR PEIRMIT k// SAN JOAQLIIN LOCAL HEALTH DISTRICT _ 1 ,. � area► 1601 E. HAZELiON AVE-, STOCKTON, CA �� ` �► Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 i 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, 1 Job Address I .l ,j 1µi z'`r� ,/�rT.-ter _L� City Lot Size PM_ / f� � � � s� - Phone Owner's Name ke - ` Address ~ F. " 1 1 Address ) �-" r Cantracto[ � c License Ntx�` 1 '� Phone_ ) t i' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI P SAL FLD PROP.LINE FOUNDATION ._....— AGRICULTURE WELL OTHER WELL,_�L 7 PITS/SUMPS%Z�6 INTENDED OSE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS ❑ Industrial _ - �40pen Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing < Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing = - Specifications iJ F Public (_l Other ❑ Delta Depth of Grout SealType of r ut(�;`► I ) Irrigation �1..Approx. Depth I}1 Eastern §tyface Seal installed by r. Repair Work Done ❑ Type.of Pump L2__1 H.P. State Work Done Well Destruction L7 Well Diameter '� Sealing Material (top 501 G' Depth Filler Material )Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUC ON 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 _ 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 Liner LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i r SEEPAGE PITS I 1 Depth _ Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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, ai 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signatu 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 compens tion laws of California."- i The applicant must call for all required inspections. Complete drawing on reverse side. _ a� /� _ Signed X� �/ r. —JFg,,tr9'ti. Title: ` . r^z_ r nz _ - Date. Of M _ FOR DEPARTMENT USE ONLY � � �+ 7 ,Application Accepted by L��"-ti'-� Date ` Area a ,+ Pit or ro t Inspection by --t6 0 ';i2,Z Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 [ f Applicant - Return all copies to: Environmental Health P�tt/ rvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 7- AMOUNT DUE AMOUNT REMITTED CK RECEIV DATE PERMIT'N0. INFO CASH rila.EH 13-24[REV.I/hs) 5 EH 1426 �.