89-3078 - Laserfiche WebLink

Home Browse Search

~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA �r Telephone Q091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED DEC (Complete in Triplicate) U N10�tY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th 'd� tion is made in compliance with San Joaa u.1n County-Ordinance No...549-for-sewageorlNoa.16& for well/pump and th FfilI i �W Iuin Local Health District. 1 ��f!{,�', :`t/-,` - tt•tl �S �l�LYQ� _ r Job Address �- 12- City b Lot Size PM Owner's Name Address 60 Al 2le /IJa{ R J2D diggiVX Phone 25-1 7ZZ 7— 1a y 1 W �d praq SS�f979 Phone Contractor A2A4A-T` Address 2 �'�'"License Ivo._ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER ❑ Z 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r'1 Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump f H.P. State Work Done Well Destruction Weil Diameter ' Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other i 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 C] Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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, and rules and regulations of the San Joaquin Local Health Diltrict. 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 applican ust_call for all requuyed in pections. Complete drawing on reverse side. Signed'X 26/JPi�-fL I/ �La __- Title: r (��C _-___."-�+P Date: VV ws 46 z'7tirZ F DEP R ENT USE ONLY �/ plic Y Accepted by Date _2 — Are Pito Grout I spet ion by Date Final Inspection by Date Additiana Comments: ❑ Stk 465-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO, INFO CASH �.EH 13-24 IREV.i i n sl -3 5 .00b75G EH t1-28