89-1284 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (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. �J Job Address City Lot Size PM t Owner's Name Address l_3145)1 �c� G Phone , Contractor !U* Address c' License No. 282 Phone_ TYPE OF WELLIPUMP: F"--NEW- - — -- -PLACEMENT—H -RUG-TJON_Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS F1 Industrial LJ Open Bottom ❑ Mantec Dia. of Well Excavation Dia- of Well Casing - SII D mesticIPrivate C1 Gravel Pack ❑ y Type of Casing Specifications �~ ,1` f`l Public Cl Other I Delta Depth of Grout Seal Type of Grout_..-.. _ 4 I Irrigation -___--Appro A7pth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type ump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF TIC WORK: NEW INSTALLATION I.) RCPAIR/ADDITIOqT DESTRUCTION I 1 INo septic system permitted if public sewer is ' available within 200 feet.) 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 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.`TREATME_NT PLT. El Method of Disposal I v .I � Distance to nearest: Well Foundation Property Line J F LEACHING LINT No. & Length of lines 1 0 _`..-_• Total length/size l FILTER BED ❑ Distance to nearest: Well. Foundation_. t Property Line—'�/`� � l SEEPAGE PITS I r Depth Size 7:3 5— - _ Number i SUMPS Ll Distance to nearest Well q O Foundation �� Property Line DISPOSAL PONDS ❑", I.hereby certify that I have prepared th si application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin1L'bcal'Health District. Home owner or licensed agent's signature cerlifies;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 certifi6s 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 coinpensa- tion laws of California." ' The appli n must call for required inspections. Complete drawing on reverse side^- [� Signed Title: Date: FOR DEPAR MENT USE ONLY < Application Accepted by Date Area P r Grout Inspection by T `Date Final Inspection by Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 523-7104 ❑ 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 CK INFO AMOUNT DUE y AMOUNT REMITTED CASH RECEIVED BY f f/DATE PERMIT'NO. f w 11 H 13241p1:V,iiN5Y � `•>."' EH 1428 I