89-251 - Laserfiche WebLink

Home Browse Search

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 (Complete in Triplicate) 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. Job Address l ` i 4[) W fA S.Arz- City 40 01 Lot Size 60 PM Owner's Name c./c7R JV Y�aJ�/ �Vj��N Address �+ RNEi2 r� Phon - z Contractor I1 CEJ �#_ C]IQ4 5 S Address �O U O;J! �-2� License No3/7J�-S Phon � 7� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT If DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /ZCl SEWER LINES DISPOSAL FLD. t20 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t2s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private X Gravel Pack ❑ Tracy Type of Casing /?VC Specifications M Public Cl Other n Delta Depth of Grout Seal /OA Type of Grout I I Irrigation 1-6 .Approx. Depth 11 Eastern Surfacg,Seal Installed by _ Repair Work Done ❑ Type of Pump Sy� H.P. $ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 X7 Depth A2" Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I } DESTRUCTION l I (No septic system permitted if public sewer is 9 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 b SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth 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, andl rules and regulations of the San Joaquin Local Health District. Horne 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:"I 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 c��alll for all required inspections. Complete drawing on reverse side. Signed X eC.[.[.ZSt'__/Maria. Title: (2Z4 A4A_ Date: Z-3 FOR DEPARTMENT USE ONLY z Application Accepted by Date Z-r3 Area Pit or Grout Inspectio In ff __ Dater � Final Inspection by l Additional Comments: .�Id _�� it c.w�-i!- r j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO MH a.EH1 3-241REV.r/x5j �� "L�t EH 14-26 �'� S O J