89-2065 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT oo d SAN.JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k f Telephone {209) 466-6781 PERMIT,,EXPIRES 9 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. A �� Job Address City Lot Size PM Owner's Name Address Phone Contractor Z Address _ f_ __"_ License No. Phone --- _ -- 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E) Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation..- . Dia. of Well Casing 1 ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing € � Specifications i'l Public ❑ Other #LlDelta _--Depth of Grout Seal + `Type of Grout_- ---`- I I Irfigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State,Work Done,--. ';' ,� R k __J t f[ Well Destruction ❑ Well Diameter ? . Sealing Materialltop 50') r \N t Depth - s �. Filler Material{Below 50' ). ,4 TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION [ ESTRUCTION I 1 1No septic system permitted if public sewer is ;available within 200 feet.) !!! Installation will serve: Re Hence ± Commercial_ ther i F Number of living units: Number of b ,rooms ; 1 Character of soil to a depth of 3 feet: ' f Water table depth SEPTIC TANK Au--.Type/Mfg I r _ _ Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ — Method of pl Distance to nearest: Well �50 Foundations Property Line I, �f. f LEACHING LINE L4--W..,& Length of linesF g r.* Tota len thJsize FILTER BED ❑ Distance to nearest: WellFounda"tion _ Property Line .-...... SEEPAGE PITS h _�� Size T Number SUMPS L1 Distance to nearest: Well , Foundation 1Property Line DISPOSAL PONDS ❑ / / t/ 9 hereby certify that i have prepared this application and that the work will be done'in.accordatice'with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health DiMrict. - 1 1 , Z % I - 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 no 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 pperm_it is issued, I shall employ persons subject to workman's compensa- tionZapplican alifomi The t call far II r aired n pectin s. Complete drawingon r arse side.Title: Date: Sig ; FOR DEPARTMENT USE ONLY Application Accepted by "� '-r` Date 1 Area Pit or Grout Inspection b - Date- inal Inspection by � Date � y3 Additional Commants: I ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-'Box 2009, Stk.j� CA 95201 1 FEE S 1 j —'fes`�"CK INFO AMOUNT DUE .y Ali REMITTED CASH RECEIVED BY: ' DATE'`r PERMIT NO. �� log +.EH 13-24 1 REV.I/K 5) !O � �r ^-e).. EH 14-20