89-2504 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT.EXPIRES TYEAR FROM DATE ISSUED l i (Complete in Triplicate) i! 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. Job Address 7 �,� City _r Lot Size PM r f�C Address [ - Phone Mr Owner's Name 4 L.� - j . Address c - f r . � Contractor � � License No.`� Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El -r- Y -PUMP INSTAL-L4TION`❑ "' SYSTEM REPAIR-❑" -..,..-"-•-'OTHER'❑°" { O'DISTANCE TO NEAREST: SEPTIC TANK # SEWER LINES^ DISPOSAL FLD. PROP. LINE FOUNDATION r M j AGRICULTURE WELL MOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ., ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation }' ' Dia. of Well Casing Domestic/Private ❑ Gravel Pack LJ-Tracy +t'.' Y 3. Type of Casing' Specifications Ll r Cl Other Cl Delta - Depth of'Grout Seal - Type of Grout FPublic 1- 1 N I 1 Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by r Repair Work Done L-3Type of Pump'^` x. '3 SH.PLI . " ^S`tate Work Done .: V1 t Well Destruction ❑ Well Diameter Sealing Material {top 501 ;Depth - --- .Fillerf;Material (Below 50'i !TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION [ I� DESTRUCTION l I (No septic system permitted if public sewer is i Y 1 x )ilf+�*• _ available within 200 ieet.l ' Installation will serve: Residence.: e—Commercial Other ` Number of living units: Numbet of'bedrooms . Charactef-of soil to a depth,of'3 feet:•_' /9`il�ir4 jy Water table depth - 77" :.y No`Compartments SEPTIC TANK- ❑ Type/Mfg _ p�L� Capacity — PKG. TREATMENT'PLT. LI �„ Method of Disposal Distance to nearest: Well'_-.— Foundation Property Line 42 LEACHING LINE No. & Length of lines "ems ToF=-tal7-length/size FILTER BED ❑ Distance to nearest: WellA-0 Foundation % Property Line i k SEEPAGE PITS I I Depth Size — Number F SUMPS Distance to nearest: Well01t' Foundation y Property Line EI r DISPOSAL PONDS ❑ II 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 1 rules and regulations of the San Joaquin Local Health-Di§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 shah 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- tionlaws of Cailfgfnia." .I The applicant must call for Orequi d inspections. Complete drawing on reverse side. Signed X �'` Title: Date: } # FOR DEPARTMENT USE ONLY � :I mil Jo Application Accepted by - h~ Date Area i� Pit or Grout Inspection by Date Final Inspection by ate � �t F Add itional'Comments: 'Afo !�-�� t^ r !a (, C] Stk 466-6781 E-) Lodi369-3621 ❑ M nteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � II CK t ffFEEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. a.EH13-24SREV-r'/H5] '4 � `-AEH 14-26 %