89-1349 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT f r� 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) 3 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 we I/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 Job Address 0 s')u M6enC AveCity Lot Size PM r t ON Address Phone Owner's Name ' { it*i CARC'Le /S o A) At/ i 2y39r� Contractor Address License No. Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑-' ,J}ii y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,y,;, �, OTHERi ❑_ , 1 I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE ` � 4 I PITS/SUMPS ` FOUNDATION AGRICULTURE 1NE}:L -OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 71 Ll industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �1Specifications l1 Public F1Other I {I s Delta Depth of Grout Seal 'i Type of Grout _. tv I I Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by - C h1 - iState Work DoneRepair Work Done ❑ Type of Pump H.P. O 4 � _ F Weli Dev LJ Well Diametei.....+✓ Sealing Material )top 50'1 a � Depth.- Filler Material {Belo;PL 50') EI' i TYPE OF SEPTIC WORK: NEW INSTALLATION i 1-,ACP.AIR/ADDITION ! DESTRUCTION I I (No septic-system permitted if public sewer is available within 200 feet.) ,. 'Installation will serve: 'Residence-_.—✓ Commercial-13 Other N tuber of,living units: Number of Brooms Character"'of soil to a depth of 3 feet: APPY - { _Water table depth SEPTIC TANK ❑ Type/Mfg_ l Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ry No. & Length of lines�._ Total length/size FILTER BED Distance to nearest: Well Foundation Property Line s i SEEPAGE PITS I I` Depth Size Number ADD UAP x�STIW6 k SUMPS Distance to nearest: Well Foundation Property[t_ine f ,DISPOSAL PONDS, CI 4 a - i i hereby certify tha -1'have prepared this application and that the work will be done in accordance with San Joaquin countyordinances, state laws, and 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 uihich`'tkEs permit is issued, I shall not employ-any person in such manner as to-become subject to workman's compensation laws of�Galiiornia." Contractor's#siring or sub contracting signature 1 certifies the following: "I certify_that in the.perform nce]of the work Jor_yvhich jhis permit is,issued,-i shall employ.persons,subject.to_workman's compensa- tion laws of California." The applicant mustfA for all,rrequ ed inspecti S. Complete drawing on reverse side. F Signed X Title: f k t -,.- � & FORI DEPARTMENT USE-ONLYr �� Application Accepted by i `_ ' "r<�Date Area a Pit or Grout Inspection by Date Final Inspection by i" Date SQL All Additional Comments: ❑ Stk 466-6781 1-1Lodi369-3621 ❑ Manteca 823-7104 O-Tracy 83546385 —6pplicant�Return alLcopies,io:,.Environmental Health-Permit/Services 1601-E=;Hazelton-.Ave—P-0-8ox•2009,-Stk—CA 95201 l FEE ` II INFO .AMOUNT DUE, AMOUNT REMITTED C K RECEIVED 6Y DATE PERMIT NO. i, ♦ EH 1 -24(REV.t/n 57 dO .�� (~ �r--�. 6-9 199-13 4 EH 144-28 v� •'kF