89-1471 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E._HAZELT•ON AVE., STOCKTCN, CA Telephone (209) 466-6781 PERMITEXPIRES 1. YEAR FROM DATE,ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Lrical 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. s Job Address —5 Q 4City Lot Size PM 1 Owner's Name Address s Phone Contractor _ ddtess �— '4� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T AGRtCULTrU, iEVELFOUNDATION L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑-.Open-Bottpop��,m, --- -----�_Manteca.,,�. Dia of WeIL xcavAdo Dia_of le-II Casing - A,. 1❑ Domestic/Private ❑ Gravel Pa&. ❑ Tracy Type of Casing Specifications I"7 Public ❑ Other D Delta Depth of Grout Seal Type of Grout_ __ + I i irrigation __-Approx.I'tiepth 1 I'Eastern Surface Seal Installed by - ,Repair Work Done LJ Type of Pump _.-. .'•i H.P. State Work Done i Well Destructibn Well DiameterSealing Material (top GG — /� Ti ! Depth 6 ' Filler Material (Below>�T TYPE OF SEPiTIC WORK: NEW INSTACLATf9N I l REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is \ 1- h available within 200 feet.) \} Installation Mull) server Residence�t Commercial_ Other � �CNumber of living units: _�Number of bedrooms ,�i I aracter of,soil to a depth of 3 feet: 1 Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments ~ iI IPKG.,TR EATMENT PLT. ❑ t Method"of Disposal /} Distance to nearest: Well.___f Foundation Property Line .:• f i t~ � �1� LEACHING LINE�``�� ❑ No. & Length of lines .s -i TotSI length/size E !, FILT�R � D Q Distance to nearest: Well �I,rq �F}o/undation ! Property Line I SEERA'fGF MTS 11 Depth Size Number E l SUMPS Ll Distance `o nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti I hereby certify that I have prepared thi application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquih-Loral_Health_D.ilirjct. c 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:"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." I t The applicant 11 req ons. Complete drawing on r ve side. ! Title: Date:. ?—z f r Signed XIF/0 FOR DEPARTMENT USE NLY �p Application Accepted by Date �r Area Pit or Grout Inspection by Date Final Inspection by 1 ` °� Date `�.1 F 7 t ` Additional Comments: _ l ° ❑ Stk 466-6781 ❑ Lod 399-3621 ❑ Manteca 823-7104 '❑ Tr cy 5-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CKI t 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INfO C�f �r�'� � y +,EH 13-24(REV.1/K 5} 1 lam/ `f � �6 g 1 I y 7 l EH 14-29 [ c!��