89-2566 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAO:UIN-LOCAL HEALTH DISTRICT 1601 E. HAZELTON'AVE., STOCKTON, CA Telephone (209) 466-6781 J-PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) application is I for sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin ` Application is hereby made to the San Jounul0rdinalnHealth ce No.District far a permit to construct and/or install the work herein described.This app made in compliance with San Joaquin County AA Local Health District. QPM / City ,Lot Size. p Job Address 4,rt: : , g. C -Phone Address p Owner's Name r2 Lice Phone 0 License No.� - Address DESTRUCTION 1:1Contractor WELL REPLACEMENT ❑ TYPE ,F WELL/PUMP: NEW WELL ❑ OTHER Ik SYSTEM REPAIR Ll PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES � PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION INTENDED USE TYPE OF WELL PROBLEMCONSTRUCTION SPECIFICATIONS pia. of Well Casing 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f ❑ Industrial Specifications F1 Gravel Pack ❑ Tracy Type of Casing Type of Grout Domestic/Private. ❑ Delta Depth of Grout Seal ^� ❑ Public ❑ Other , n E, pprox: Depth ❑ Eastern Surface Seal Installed by v i ❑ Irrigation . . f St to Work Done Type of Pump - - H.P. Repair.Work Done Sealing Material ltop 50'1 { Well Destruction ❑ Well Diameter i 1 Depth L FiAer Matrerial (Below 50'} available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAlR1ADQITION ❑ DESTRUCTION ❑ ova septic system permitted if public sewer is Commercial Others installation will serve: Residence� r i Number of..living units: Number of bedrooms } Water table depth k Character of sail to a depth of 3 feet: Ci pacity�� No. Compartments k SEPTIC TANK ❑ Type?Mfg 1 Method of Disposal C PKG. TREATMENT PLT. ❑ ' { r F undation Property tine Distance to nearest: Well " s f Total length/size LEACHING LINE ❑ No. & Length of lines Property Line Foundation_1 FILTER BED ❑ Dlstarice'do nearest: Well 4•} P ry I Number I ❑ ' Depth Size SEEPAGE PITS Property Line SUMPS ❑ 'Distance to nearest: Well Foundation=_ DISPOSAL PONDS ❑ 1 hereby certify that l have prepared this application and that the work will be dare in accordance with San Joaquin county ordinances, state laws, an ' rules and regulations of the San Joaquin Local Health District. I certify that im,ihe'performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: " of rsons subject to workman's compensa employ any person in such eman tea as thbecome e performance of othe wok for which this Perm"+t is issued,fI shall employ ape is hiring or subcontracting signature certifies the following:'I certify . tion laws of California." " The applicant must call for a quired inspections. Complete drawing on reverse side. pate: f� _ Title: Signed .. a OR DEPARTMENT USE ONLY / f � 3' ` _ Area < .- Date Application Accepted;by Date" $ Date Final Inspection b Pit or Grout Inspection by ++ Additional Comments: ❑ Manteca 823-7114 ❑ Tracy 835-6385 2009, Stk., CA 95201 C1 Stk 466-6781 Lodi 369-3621 Applicant- Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED SH / p q }- INFO �] l IO l—�S�YJ +EH 13-24(REV.i/B5) ✓ 35 EH 1426