89-1709 - Laserfiche WebLink

Home Browse Search

JJ, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I j (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. r t z OSrt 4!/TTS p�s' � �Ol Job Address { City Lot Size PM 'iJ �L rr i Owner's Name I Address f Phone2R Contractor Address 7aC / License No, d' Phone E TYPE OF WELL/PUMP: `NEW WELL ❑ WELL REPLACEMENT.0 . `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK x 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 ❑ Domestic/Private ❑ Gravel-Pack `O Tracy Type of Casing Specifications 1-1 Public ❑ Other i f 1 Delta - Depth of Grout Seal Type of Grout I i Irrigation _.-Approx. Depth I i Eastern -Surface Soul Installed by _ Repair Work Done ❑ Type of Pumpl r` H.P. State Work Done k Well Destruction ❑ We11.Diameter Sealing Material (top 501— Depth f t ¢ P ° Filler Material (Below 501 - ' ? TYPE OF SEPTIC WORK:* NEW INSTALLATION[ I -REPAIR IADDITIO DESTRUCTION [ ] Mo septic system permitted it public sewer is { available within 200 feet.) Installation will serve: Residence commercial_ Others' _ T Number of living units: r Number of bedrooms t Character of soil to a depth of 3 feet: F ✓Water table depth LL Ir SEPTIC TANK ❑ T e/Mf`' t YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal -Distance to nearest: Well Foundation Property Line LEACHING LINE &' O No. & Length of lines . / — 0' /�� _� Total length/size 4wo Il FILTER BED ❑ Distance to nearest: Well_ �G Foundation %� Property Line i SEEPAGE PITS 4e Depth;} 2 Size_.._._. .�/~CAit Number SUMPS ❑ Distance to nearest: Well Foundation �� Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this appiicaticin 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: "!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 cal all require i pecti s. Complete drawing on reverse side. Signed X Title: Date: 7 Zpr r y' FOR DEPARTMENT USE ONLY Application Accepted byC_ iILdate ✓�Zv"� Area �.w Pit or Grout,inspection by Date ,Final inspection.bye Date Additional Comments: y ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 623-7104 ❑ Tracy 835-8365 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTDUEAMOUNT REMITTED CK 4 CASH RECEIVED BY DATE ((( PERMIT'NO. f.Eli 124 IREV,t/H y) EH 14-4-28