89-70 - 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 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. r Job AddresslvjCity tot Size PM Owner's Name Address PhoneY ? 6-060 Contractor44 Address�710& E X44,� License N W 91 Phone S 5-02 2 TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Y PUMP INSTALLATION ❑ 5 STEM REPAIR ❑ OTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca D. . f Well Excavation Dia. of Well Casing El Domestic/Private L-1GravelPack Ll Tracy ype of Casing Specifications M Public F Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth :ixFiller Material (Below 50'I �- TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION 1 I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet./ _ ^a Installation will serve: Residence_v"Commercial_ Other i'1 Number of living units: Number of bedrooms_q J Character of soil to a depth of 3 feet: oft i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: -Well Fou[�T Foun ation Property Line LEACHING LINE ❑ No. & Length of lines ` Totaall length/size FILTER BED ❑ Distance to nearest: Well!0 ? 0 it Foundation_( Property Line SEEPAGE PITS I I Depth J Size _ Number SUMPS Ll Distance to nearest: Well Foundation x 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, and rules and regulations of the San Joaquin Local Health Dt%trict. 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 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." The applicant ust call for all wired ins ctions. Complete drawing on reverse side. Signed X Title:_��I"}i.C/l. Date: ... v FOR DEPARTMENT USE ONLY Application Accepted by Date r- RY Area �J _ 6 t or Grout Inspection by Date Final Inspection by �l t G -Cl Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 EE CK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-241REV.1/H5Y l .EH14-28 �� 7s.3