89-1836 - Laserfiche WebLink

Home Browse Search

` ✓y1 APPLICATION FOR PERMIT � 't SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE. STOCKTON CA Telephone (209) 466-6781 JUL a 11989 PERMIT EXPIRES IL YEAR FROM DATE ISSUEDi"V 1R01UME (Complete in Triplicate) PERP 1VTALN r �r ISE R 17CPQ`rf'� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T ^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. ! I Job Address SO a/- City Lot Size PM k Owner's Name s�LJrx I 'f*'`----- Address _ �� Phone Contractor �/11- Addtes40_ /_6 0't4� Lice e No.4`ZF__1- Phone t TYPE OF WELL/PUMP: NEW WELL 0-,: WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT10N,Q ;' SYSTEM REPAIR OTHER ❑ 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 ! )�Qomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation __-Approx. Depth t I Eastern )surface Seal Installed by _ Repair Work Done Type of Pump H.P. I — State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material {top 501�_ 3"�� Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 Meet.) t .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 .� o F PKG. TREATMENT PLT. ❑ ti � Method of Disposal r � Distance to nearest: Foundation - Property.Line LEACHING LINE r❑ No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: Well -Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number "4 SUMPS ❑ Distance to nearest: Well Foundation Property Line " DISPOSAL PONDS C3-- I "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: 1 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 must call for gill required inspEctio s. Complete drawing on re arse side. Signed X Title: `� ✓ _.— Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date U / A Area Pit or Grout Inspection by Date Final Inspection by 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. Bax 2009, Stk., CA 95201 d FEE CK V 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. +.EH 13-24 IREV.r/w 5] 3 S •utJ C (� 1 f�1 �G ,-F3/_ EH 94-26 Q f Q_{ O '_ W t ..