89-690 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA x' Telephone (209) 466-6781 1 ' � 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'h i-d.R described. This-Saappn Joaquin is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ariif Regulatio of theS�n Joaquin Local Health District. Joh Address City = Lot Size PM Owner's Name Address �> yrti Phone Contractor Address e �� License NoZ 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 1 .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'i Public -i-I Other k ❑ Delta Depth of Grout Seal Type of Grout -- i I Irrigation �_Approz. Depth I 1 Eastern Surface Seal Installed by r Q Repair Work Done ( Type of Pump �-�L� — H,P. �J State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 t, Depth ,Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial —ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg A Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line t t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size Number SUMPS L� Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ A I hereby certify that i have prepared Phis-application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the'San Joaquin local Health Di§trict- 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, 1 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 i tion laws of California." The :ppl,can st call for all required inspections. Complete drawing on rse side. Signd —�Ali_ r , Title- Date: 3 �� r I F R D ARTMENT USE ONLY O . Application Accepted by Date Area .. •��.�. Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f y FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. INFO +.EH 13441REY,riit5l EH 14-2a �`