89-2366 - Laserfiche WebLink

Home Browse Search

. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED !�O ��. (Complete in Triplicate) SEP 22 Ift Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew in described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RuAkiH�t�i 'FI Joaquin Local Health District. +(;€S Job Address IfQ wI City Lot Size PM _. Owner's Name %_.,_D . Address 3q 7 r A ZSJ!`:g Z?A Contractor Address ., 16 6442 ,L..,_ o. Z- Phoned- 29rl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0111� Y-,'* SYSTEM':REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "' DISPOSAL FLD. PROP. LINE ; :�;_ :x-FOUNDATIOW AGRICULTURE WELL. OTHER-WELL PITS/SUMPS-.--- INTENDED ITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public Cl Other .1 11 Delta Depth of Grout Seal Type of Grout I I Irrigation ___Approx. Depth l I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump.,�r H.P..3 State Work Done -� t I -f"S�-WWell Destruction ❑ Well Diameter I Sealing Material (top 501 -� Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is f t available within 200 feet.) Installation will serve: Residence_ Commercial Y.._ Other Number of living units: Nu`mbe of'bedrooms 1 \ Character of soil to a depth of 3 feet'--- —� Water table depth SEPTIC TANK 0 Tyj5e/Mfg Capacity No. Compartments PKG.,TREATMENT PLT. ❑ ,f.x h� Method of Disposal [ DistaWrto-nearest: Well Foundation Property Line LEACHING-LINE -^- Cl No.-&'L-ength_of-lines. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lie d SEEPAGE PITS f I Depth Size Number SUMPS L'i Distance to nearest: Well Foundation Property Line_ DISPOSAL�PONDS- - ❑ F I hereby certify that 1 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 District. 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 applic2m��t pections. Complete drawing on reverse side. Signed X � r Title: iL� Date: OR DEPARTMENT USE ONLY �p Application Accepted by A Date Area e- Pit or Grout Inspection by ' Date Final Inspection byV_Lte� ,0ate 2� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 CK kFEE AMOUNT DUE AMOUNT R/(EMITTED CASH RECEIVED BY DATE /PERMIT NO. iEH 3-24 EH1628IflEV.r/A51 C�