89-2383 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT F F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 3 (Complete in Triplicate) work . This cation is ll the Application is hereby made to tcounty Ordinauin lncfe No.549 for sewage orealth District for,6 'No�1862 for construct and/or and the Rules and IR Regulations of the San Joaquin made in compliance with San Joaquin Local Health District. t c III I PM City PM City Lot Size Job Address Owner's Name –DW.I Address �7� Phone j ;t r Address License No. Phone ' Contractor i TYPE FF—WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PlT51SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing p,industrial If Open Bottom L] Manteca Dia. of II Excavation .1 T e'of Casing Specifications ❑ DomesticIPrivate C1 Gravel Pack F1 Tracy YP Type of Grout — f"i Public " C7 Other 1 C7 Delta Depth of Grout Seal `1 I Irrigation I,' "�.-Apprpk. Depth l I Eastern Surface Seal Installed by --` State Work Done Repair Work Done ❑ Type of Pump H P Well Destruction ❑ Well Diameter Sealing Material (top 501 l i Filler Material (Below 50') Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( i DESTRUCTION I I avlailabptic sy t m feeitled if public savJer'is.,, f r ` Installation will serve; Residence Commercial Other Number of living units: Number of bedrooms ? Water table depth Character ofisoil to a depth of 3 feet. "'';f: - Capacity ' No. Compartments SEPTIC TANK _. ❑ Type/Mfg Method of Disposal PKG-:TREATMENT PLT. ❑ W` ,S _cY J�� J t s V 4 Distance to nearest: Well / Foundation 0I Property Line y l /�.'k `ti Total length/size 'v� LEACHING LINE r �IY No. & Length of lines r Property Line -- r FILTER BED ❑ Distance to nearest: Well .Foundation SEEPAGE PITS I `Depth'`t� H Sire 13 K Number — = l SUMPS P( Distance to nearest:" Well r� Foundation Property Line : F\ DISPOSAL PONDS ❑ " " ' ' I hereby certify that I,have prepared this application and that the work will be done Arr accordance with San Joaquin county ordinances, siatte;lawsy and rules and regulations of the San Joaquin local Health Di§trict �,` "� ai, '� (' Home owner or licensed=agent's signature certifies the following: "1 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 Calitorniaa' Contractor's hiring or sub contracting signature certiTies the folbwing:"I certify that in the performance of the work for-which this permit is issued?f shall employ persons subject to workman's compensa `f'tion'laws of California." e; i The applicant must call for all requir inspections. Complete drawing on reverse side,, ' Title, Date: 94 Signed X M � F15R DEPARTMENT USE ONLY �f' •. •. �.�... "I•• Date Area j Application Accepted by L; i Final inspection by' ate ' g. Pit or Grout.Inspection by i Date _ Additional'Comments:., ' t ❑ Stk 466-6781 a I❑ Lodi A-3621 ❑ Manteca 823-7104 E3 Tracy 835 5385 Applicant—Return all copies to: Eni ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE CK RECEIVED BY BATE PERMIT ND. INFO ;AMOUNT DUE ti AMOUNT REMITTED CASH .4 .• H . �� •,�:�.� _gid.. �� . �;-,C �.�.. 6 ..�-- "mss�'T�"' �=�3�3 ..E 13- IRk7l EH'S4�2e