89-1428 - Laserfiche WebLink

Home Browse Search

t--r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone {209) 466-6781 PERMIT EXPIRES TYEAR 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" Job Address o", �9S 1— ` a y City Lot Size tau PM Owner's Name � �` �a' .�.?P`� AddressPhone �e _ Contractor .` + �" �fy,- "" ZAddress i� � � License No.� � I I Phone ��'" 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED-,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work:Done ❑ Type of Pump H.P. State Work Done Well Destruction' ❑ Weil Diameter Sealing Material Itop 50') y Depth Filler Material (Belo2 501 _ TYPE OF SEPTIC WORK: NEW INSTALLA'''TION l 1 REPAIR/ADDITION DESTRUCTION l 1 INo septic system permitted if public sewer is r ", E available within 200 feet.) y Installation will serve: Residence ZCommercial_ ther Rep r4�Ce e��IC i A�L { Number of living units: Number of:be Character of soil to a depth of 3 feet: _Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ t �o r / r Method ofppoosel � Distance to n��rett: well Foundation / Property Line rr� f r LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS l 1 Depth Size Number SUMPS $ Cl Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j 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: "!certify that in the perfor ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ' d t The applicant or all re �d inspec o s. Complete drawing on reverse side. Signed X •. Title: l� � Date: I � .e'f FOR DEP,�RTIVIENT.USE ONLY Application Accepted 6y „. Date � "- ,Area Pit or Grout Inspection by Date Final Inspection by' -- Date a f 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.--- - --^�--�- INFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT NO" + EH1 3-24IREV.iins) ® EH 14.28 .. 'Z/�