89-1662 - Laserfiche WebLink

Home Browse Search

! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s r.�,„f. y, 4 1601 F. HAZEL T ON AVE., STOCKTON, CA -'Telephone (209) 466-6781 PERMIT EXPIRES.1=YEAR'FROM 'DATE ISSUED" � :� (Complete,in Triplicate) E' "'�' ``� Appliin cation is hereby made to the San Joaquin Local Health District for a permitVto construct install the work herein described.`This application is Local HealthpDistrictwith San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Job Addressr 4 g�ITP 5 i I4, ,I •,.af i. i s;„;r ij -rYrt City Lot Sae PM = Owner's.Name P.l�t/L. } ! � ii u M� .Address - -Phone Contractor F e,�at% Address TYPE OFWELL/PUMP: F License Na Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s °PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST:,SEPTIC TANK OTHER ❑ SEINER LINES �� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 1 INTENDED USE -OTHER'WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ”" ~ ❑ Open Bottom ❑ Manteca—� y Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑'Tracy ❑ Public ,�- Type of Casing Specifications ❑ Other .� ❑ Delta Depth of Grout Seal t ❑ Irrigation _._Jgpproz Depth ❑ Eastern Type of Grout Repair Work Done ❑ T Surface Seal Installed by YPe`of Pump H.P. State Work Done ~� A- _ Well Destruction ❑ well Diameter Seaiing'Material (top 501 ,Depth �,F,lier Material (Below,501) TYPE QF SEPTIC WORK: NEW INSTAL ION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permittedif Public P available within 200 feet.) t P sewer is 6 Installation will serve: Residence! Commercial ` Other_ � N ” Number of living unit§: ;'Number of bedroo s Character of soil to a depth 3 feet: SEPTIC TANK •--Water table depth ,,, r N PKG. TREATMENT PLT'. ❑ Type/Mfg y C $ Capacity _ No. Compal•[ants x " ` � - Distance to nearesf: w. .A Welf `! Q ;.g;,, 4 Method of Disposal _ Foundation— �� Propertyfne_ _ } q LEACHING LINE i rvo. & Length of lines 4, ;� ,0 FILTER 8ED ❑ Distance to nearest: Well �otaf.length/size �d Foundation ++ s d — —.Property Line SEEPAGE PITS Depth s Size— -; 36 N tuber SUMPS r ❑ Distance to nearest: Well'r> ` DISPOSAL PONDS ❑ I dFounrlaion,]� Property Line I hereby certify that f have prepared this application and that the work,50i be`;dor�i-irraccordance with San Joaquin county ordinances, state laws; and f' rules and regulations of the San Joaquin Local Health District. �` yam- , Home owner or licensed agents signature certifies the followiri : "I°cep � employ an g rtify that in the performance•of:the work for which this P Y e person in such manner as to become subject to inrorkmari's compensation laws of California.'' Contractor's hiring or sub-contracting signature permit is issued, I shall not certifies the following:"I certify.that in the performance.of the work for which this permit is issued'I shall employ tion laws of California."' p y persons subject to workman' com '�'� f \ pensa- The applicant must c II for all.re uired inspection. Complete drawing an reverse side. y. Signed w J r y� ✓4' ""*'.� _ h ' Title:` - - r g t: A' t Date: F DEP M_ENT USE ONLY Application Accepted by 'iDate .� �✓ . y y a i...J t r Grout Inspection by Area +Date Final Inspection by Additional Comments: _ 7kti ❑ Stk 466-6781 ❑ Lodi 369-3621 E -❑ Manteca 823-7104s,W.• ❑ Tracy 835-6385• r Applicant- Return all copies to: EnWonmentaf Health_ P;Fr t/Services 1601 E. Hazelton Ave.,.P,O. Box 2009,.Stk. CA 95201 3 ti +r FEE INFO AMOUNT DUE_, AMOUNT REMITTED "CK# }r} CASH ; RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.t/esl EH 14-26