89-414 - Laserfiche WebLink

Home Browse Search

I , APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application-is,heleby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is j! made in compliarice with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address �- city �C of Size PM �IN6 Owner's Name/i 6/do Address Phone' Z 4` ' � I Contractor� �C�IVOX`- Address/._3 �r icense No. Phone " TYPE OF WELL/PUMP: NEW WELL ❑ T WELL REPLACEMENT ❑ DESTRUCTION ❑, �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL.,f OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Fi cavation Dia%of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public I-i Other Cl Delta -Depth of Grout Seal Type of Grout 11 Irrigation f Approxi Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 50') _ ,} f y s Depth.-4 Filler Material (Below 501.1 TYPE-OF SEPTIC WORK: NEW:INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is lO F / available within 200 feet:) r� . Installation will serve: Residence Commercial_ Other ~` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t't L Capacity Z6 66 No. Compartments r PKG.-TREATMENT PLT. ❑ i Method of Disposal i Distance to nearest:. - .Weil foundation�s� p 'Property Line ! o. LEACHING LINE ❑ No. & Length of lines Total length/size I I FILTER BED ❑ Distance to nearest: W Foundation�1 Property Line "� SEEPAGE PITS 11 Depth !t Size Number ! SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing "I certify that in the performance of the work for which this permit is issued, I shall not employ an rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifie a fol wing: "I certify that in the perfor a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion ws of lifornia." ' Th ap c t t It or all require Ins tion omplet ra e ' e. Signe Date: -� i P TMENT USE ONLY Application Accepted by Date Area i d Pit or Grout Inspection byD to Z. Final Inspection by _ Date_ ' ! Additional Comments: I t3 L ❑ Stk 466-6781 ❑ Lodi 36 -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE r INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. �_ I i r.EH 13-21/REV.I/K51 r 3 ' EH 11-2$ C Al—{ 89 _`7 i