89-40 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. �y Q Job Address '3' �t1 Q T A,& City.J12�.t1�L`G/9 Lot Size PM Owner's Name 46k 16 TX� 4F Address .fi~! o� /Vd�%Ir�$�/ Phone Contractor A, Address .e), /YJ/�i9 License Na� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -- DISTANCE TO NEAREST: SEPTIC.TANK._...._ .. `a,SEWER LINES - DISPOSAL FLO. PROP. LINE 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 1'1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation --Approx. Depth Ii Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth - Filler Material (Below 50') N TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION X DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence v Commercial— Other I Number of living units: -.I-_____ Number of bedrooms Character of soil to a depth of 3 feet: -5 - 3 Water table depth 7 SEPTIC TANK Cl Type/Mfg - L�i Capacity_ No. Compartments PKG. TREATMENT PLT. D �--�� p�� Method of Disposal Distance to nearest: Well -s.1 Foundation 1. Property Line LEACHING LINE lelNo. & Length of lines =�fl�7 Total length/size c �s� FILTER BED ❑ Distance to nearest: Well _—Foundation 00P_7 Property Line SST SEEPAGE PITS ( I Depth Size Number SUMPS Ll 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 accordancewith 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: "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." The applicant must call for requd ins ctions. Complete drawing on reverse side. / /,4— Signed X / Title; �C/ Date: 1 OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:' ❑ Stic 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH1 -241REV.1/M5l EH 144-28