89-2521 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA �4. J Telephone (209) 466-6781 •rte_ � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fiY�f% iia !I (Complete in Triplicate) Application is he+eby 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 l Local Health District. l I Job Address l/6�IAl�+ ! City Lot Si a PM Owner's Name Address L ��I'FYf &&1ZA Phone' 4�'s`2 ,31 �� Contractor z esl�Address +t!'i�d4f,� �,g�r3�_icense No. 3146. — Phone�7^�y &1� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. - OTHER WELL PITS/SUMPS- _- .•+T? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E f�QomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications I-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. OU-12— State Work Done Well Destruction ❑, Well Diameter Sealing Material (top 50') DepthFiller Material (Below 501 TYPE OF SEPTIC'WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is d a" I' available within 200 feet.) ? h Installation will serve: Residenceµ' Commercial-.,_ Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: _ Water table depth _ SEPTIC,TANK ❑ Type/Mfg Capacity `' No. Compartments ^' PKG. TREATMENT PLT. ❑ .. l . Method of Disposal r } Distance to nearest: Well Foundation Property Line n ! � C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER!BED ❑' Distance to nearest: Well Foundation Property Line ${ r SEEPAGE PITS i I Depth . +-Size ' Number { �SUMPS _ 1A I Distance to nearest: _,Well1 ti Foundation .Property Line w DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k rules and regulations of the San Joaquin Local Health District. 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 The applicant st c II- all reqs' d• s Complete drawing on r verse side. SignedX �Title- -5 09 _.._ Date: -- 'i r FOR DEPARTMENT USE ONLY Application Accepted by Date/ Area Pit or Grout Inspection by �I Date � �^ Final Inspection by Date A) I, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ antaca 823-7104 ❑/fracy 835-6385 — Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. NFO L + EH EH 14-28 13-24 1 REV.i i H 51 3 5' �r�! .! 1