89-1079 - Laserfiche WebLink

Home Browse Search

P A Y M E N'I° II RECEIVED APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT MAY 10 1989 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITISERVICES I!: (Complete in Triplicate) il 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. HI II ' Job Address City Lot Size PM Of— Owner's Name ress p��J ®/Je/- r -f Phone r li Contractor Address 5^ •License No.Y _Phon� TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 21� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL TPROBLEMAREA CONSTRUCTION~SPECIFICATIONS ❑ Ind trial 17Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing !i °omestic/Private ❑ Gravel Pack icy Type of Casing Specifications I'1 Public n Other F71.-Delta Depth of Grout Seal Type of Grout I I it �I Approx. Dept I 1 Eastern Surface Seal Installed by ` Repair Work Done ❑. Type of Pump H. State State Work Dane 1 Well`Destruction ❑ Well Diameter Sealing Material (top 50'1 f ,r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l I Wo septic system permitted if public sewer is Ip available within 200 feet.) Installation will serve: Resildence— Commercial_ Other Number of living units: �I Number of bedrooms Character of soil to a depth13.,of 3 feet: Water table depth E SEPT IC TANK ❑ EType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .� Method of Disposal, Distance to nearest: Well Foundation Property Line i1 LEA'CHING' LINE ❑ No. & Length of litres Total length/size FILTER BED ❑ !Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 �hDepth Size Number SUMPS Ll F.Distance to nearest: Well Foundation Property Line -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 rules and regulations of the San'Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "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." II The,applicant must call for all required inspections. Complete drawing on reverse side. Sig ed X /-�� '! �-� _ Title: Date: II F DEPARTMENT USE ONLY $' Application Accepted by I Date �r� '`-f-- Area Pit r Grout Inspection by I! Date_ Final Inspection by Z--5—ex Date LIZ Additional Comments: Ih ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M5 Aplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Cgp I RECEIVED BY DATE PERMIT NO. INFO ♦ EH 13-24{REV.t/nsl ` Hsi 1"91-4o7j EH 14-28 � .—?� i