89-413 - Laserfiche WebLink

Home Browse Search

� 3 ' rr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES iYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sa Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaq Ordinance No. 5e�%for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. � _// ' Job Address City -Lot Size � �'�' PM k Owner's Name S'1""'/� �1'✓n0d Qi AddressPhone = .,. -�- - _, '1 ._....per T.... { 'Contractor u L-a-f Address_ �3 ryi5 'uLicense No. �" Phone�� m TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] J SYSTEM REPAIR]❑ OTHER ❑v ` DISTANCE TO NEAREST: SEPTIC TANK 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 t G] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public I C1 Other " Cl Delta' Depth-of Grout Seal - = Type of Grout I I Irrigation Approx. Depth ( I Eastern Surface Seal Installed by )_ Repair Work Done LJ Type of Pump H.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Material ltop 501 Depth r �" Filler Ma'tehal (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is _ iavailable within 200 feet.) i } ! Installation will serve: Residence Commercial� Other Number of living units. Number of bedrooms Character of soil to a depth of 3 feet 40*fr + ''Water table depth SEPTIC-TANK VType/Mfg Capacit �1 ,. i Y No..Compartments t PKG.-TREATMENT PLT. ❑ s.rx �_ Method;of Disposal I i Distancd'to nearest: Well Foundationfh Property.Line' LEACHING-LINE No. &'Length of lines O r Tota length/size IF FILTER BED .❑ Distance to nearest: Well Foundation Property Line __,_,_ - SEEPAGE PITS a I I$ Depth { dire Number M1 SUPAPS L-1 41. Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS r ❑ i 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 rules and regulations J 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 fovwhict. this permit is issued, I shall not i employ any person in'suoh 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, 1 shall employ persons subject to workman's compensa- tion,laws of California." ,(--The-applicant-must call for all required inspections. Complete drawing on reverse side. x Signed Title: Date: x , FOR EPARTMENT USE ONLY ' / a _2— Application Accepted by 'J- Date 0 0E Area Pit or Grout Inspection by Date Final Inspection by Date x - Additional Comments: 1 l:k ❑ Stk 466-5781 ❑ Lodi 369-3621 El Manteca 823-7104 O Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q, Bax 2009, Stk., CA 95201 Lo FEE )NFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'N0. k !„t: ♦ EH13-24iREV.i/x5) ' EH 14-28' r�