89-672 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 1P P, H7 I SAN JOAQUIN LOCAL HEALTH DISTRICT RF _1VFD 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 AQ PERMIT EXPIRES TYEAR FROM DATE ISSUED t (Complete in Triplicate) ONMENTAt HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein Oast r s application is made in compliance with San Joaquin County Ordinance No. 549-for sewage or No. 1862 for wewpump and the Rules and Regulations of the San Joaquin Local Health Job:Address f City Lot Size PM Owner's Name f- Address A r P Phone Contractor S {'t?5 Address COL'Ic )se No. n?�fb]f/3_Phone_ 6` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11DESTRUCTION ❑ PUMP INSTALLATION M SYSTEM REPAIR ❑ �OTHER 131 DISTANCE TO NEAREST: SEPTIC.TANK ',ft"t SEWER LINES DISPOSAL FLO. PROP. LINE I 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 ❑ Domestic/Private v Gravel Pack 1 Tracy Type of Casing Specifications N Public ❑ Other l ❑ Delta Depth of Grout Seal f Type of out L k `& I I Irrigation —.Approx. Depth l I Eastern Surface Sedl Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction 4 ElWell Diameter Sealing Material (top 50') .t Depth J Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is - available within 200 feet.) I� Installation will serve:' Residence Commercial_ Other ! Number of living units: Number of bedrooms tf Character of soil to a depth of 3 feet: Water table depth a. SEPTIC TANK 4 ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT-PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I h LEACHING LINE [77 No. &:Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth a Size Number , SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS ❑ I hereby certify that l 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 shalt 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 4 certifies the folio ing: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- t tion laws of Calif rnia." i The appli st colt for all required spections. Compl to drawing rAl? se t r Signed X isle: - Date: -:DEP MENT USE ONLY Application Accepted by Date 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. Box 2009, Stk., CA 95201 1 _ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.i/a sf O Cho A '104/�I Z� EH 14-26