89-371 - Laserfiche WebLink

Home Browse Search

elm 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jp Job Address T 015 10,61 �� J-P-0 - City "K Lot Size PM Owner's Name �" �YT e J+� �Address T �D� ��/ / Rd Phone �y� Contractor N s Addressc;? ' i� �g&ense No. Phone i TYPE OF WELL/PUMP: ti NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOWW PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �. i ; . *FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� , 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private L7 Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other 1-1 Delta Depth of Grout Seal �i0 Type of Grout _ I i irrigation �IPApprox. Depth I I Eastern Surface Seal Installed by _ Repair,Work Done ❑ Type'of Pump f1 Hyl. State Work �Done - Well Destruction WellDiameter �4�66eaiing Material Itop 50'1 c:'.1we"e�X 4i`f fr3.�,c1a�.�i a Depth 1. -1750'? 13�Z�Fiiler Material (Below 501 f( c &C41 �n TYPE,OF SEPTIC WORK: NEW INSTALLATION [1—REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is i i I� y ,J I available within 200 feet.) Installation will serve: Residence_ Commercial_� Other r' , sf It t a 1 , Number of living units: Number of bedrooms Character of soil to a depth iif 3 feet: + _ ` Water table depth SEPTIL TANK ❑ Type/Mfg <Capacity— No. Compartments } PKG. TREATMENT PLT. ❑ I� 1 Method of Disposal 3 kA 1f-_, Inti Distance to nearest: Well_ Foundation Property.Line V. . LEACHING LINE ❑ N4o. &.Length of lines Total length/size ,1 , FILTER BED ❑ Distance to nearest: Well ' ' Foundation Property Line SEEPAGE PITS 11 Depth Size ti Number I SUMPS L1 Distance to nearest: Well ""'"""t Foundation r ;Property Line DISPOSAL PONDS ❑ �� 1 � 4 r I hereby certify that I have preplared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of"the Sari Joaquin Local Health Di1trict. 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." The applican u of if requir i ns. Complete drawing ori ev rso side. I Signed X 1 Title: Dater 2 FOR DEPARTMENT USE ONLY � I Application Accepted by Date Area 64 Pit or Grout Inspection by` �!ZT Date 4844 Final Inspection by Date Additional Comments: "/i f�__" � - _ ti-.[L�-�'C csti-6-. ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies tar: Environmental Health Permit/Services 1{6,01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 I r- INFO _AMOUNT DYE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. ♦.EH u —1 -24 iREV.1/x 51 ,O hnq ' 31 1 EH 144-2t1 �/ �- LLL I `-9 Tr (a 11 { � ,I 1