89-706 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address 1 1 �• Q �-SL 1�A. City Lot Size PM Owis Name Address �� Phone —9a =*��I.Contract�r Address k_ License No. 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 d f :,� ,z wr FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS ' v INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Iridustrial' 'r w" �``❑ Open-Botibm ❑ Manteca pia. of Well Excavation Dia. of Well Casing,,, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications,, .`{.. ❑ Public F) Other ❑ Delta Depth of Grout Seal Type of Grout .- 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction -❑ Well Diameter Sealing Material /top 501 I Depth Filler Material (Below 501 1 i TYPE'OF SEPTIC WORK: NEW INSTALLATION f l REi'AIWADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is 1 available within 200 fe t.1 Installation will serve: Residence Commercial_ Other F1t'1{�-ls.� F Number of living units: Number of drooms Character of soil to a depth of 3 feet: Water table depth S SEPTIC TANK " ❑ Type/Mfg- �� '.Capacity No. Compartments Y�:yPKG. TREATMENT"PLT: ❑ - �. # �Y Method of Disposal Dista n to nearest: F _Well Foundation Property Line LEACHING LINE 0,,No.' &-L'endth of lines Total length/size FILTER BED 'ElDistance to nearest: Wel! Foundation Property Line SEEPAGE PITS Depth -5 Size — .- Number clk i SUMPS ❑ Distance-to-nearest: 4 .Well Cfr Foundation _....._--__ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that;`the.wock'vi ili be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-Health District.' ` Home owner or licensed agent's signature certifies the following:-'1 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 thafin the performance,of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion 1 tion laws of California." -' 1" ' '? r - — i The applicant m t call for ail u inspections. Complete drawing onreversesid Signed X Title: �a Date: �9 ! t ` 9 FOR DEPARTMENT USE ONLY Application Accepted by -- Date Area Z Pi r Grout Inspection by :eW4`55* Final Inspection by Dati� 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIYNO, INFO CASH +.EH 13-24(REV.1195) < Ip, q - 3 EH 1426 5 ^'P 1 7Q ]