89-2073 - Laserfiche WebLink

Home Browse Search

r .� APPLICATION FOR PERMIT CHuuG SAN JOAQUIN LOCAL HEALTH DISTRICT �Q 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t 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. Z "'_ City Lot Size PM Job Address L :;; �Address �"' Phone Owner's Name - —� - Contractor O Address License No.owaevo / Phone w x TYPE OF WELL/PUMP: NEW WELL EJ :WELL REPLACEMENT ❑ DESTRUCTION El4 PUMP INSTALLATION ❑. SYSEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -'SEWER LINES c DISPOSAL FLD. PROP. LINE e �"��FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA., CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca sf [)ia. of Well Excavation Dia. of Well Casing ❑ Domestic Private ❑ Gravel Pack ❑ Tracy 'Type of Casing r - Specifications M Public ❑ Other ❑ Delta (-Depthiof Grout Seale Type of Grout e I I Irriyation1 --.Approx. Depth 'I,] Eastern :Surface Seal Installed,by p H P. ' n State Work Done Repair Work Done ❑ Type of Pump r,f Well Destruction Ll Well.Diameter . Sealing Material Itop 50 -- „ �\ r aterial IBelow 50'1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ OITION DESTRUCTION (No septic system permitted if public sewer is` L j+ available wi rrt_2 t.} `/4Z �r Installation will serve: Residence A Commercial `Other ° o� x(A -5 ,4�%/T �(��/ �'T �" %+ f � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: , � ,' water table depth SEPTIC TANK EJ Type/Mfg '`�. r ' )CaDacrt No. Compartments PICC TREATMENT PLT. ❑ r `' R�.Method.of Disposal ! � Ni Ij Distance to nearest:r Well f-Foundation / Property Line E LEACHING.LINE L1No. &Length of lines i �--- -' ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' a SEEPAGE PITS I I Depth dr Size _ *' Number [� SUMPS L-i Distance to nearest: Well Eoundation Property Line F ^P�10 DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that tFie work wilt-be clone 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's4gnature 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_o-workman's-compensation laws of California."Contractor's hiring or sub-contracting signature certifies the.followi : "1 certify that in the performance of the work for which this permit is issued,t shall em persons subject to workman's compensa- tion laws of Calif n . ' s The:eppli ntcall for re s mplete drawing o reverse side r gnarl f Title; ate: FOR DEPARTMENT USE NLY Application Accepted byCM Date y Area Pit or Grout Inspection by el Date Final Inspection by Date 2$ I. lC Additional Comments: ElStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant -:Return all copies to: Envifonmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED By DATE PERMIT'NO. INFO /, + EH 1324 MEV.i/9 5) ( EH 14-2e �'