89-603 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT PAYMENT >. SAN JOAQUIN LOCAL HEALTH DISTRICT R ECF-I 'ED 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG Telephone 12091 466-6781 'l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMITISERVICES 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 Couny Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joa Local Health District. SAN JOAQUIN LOCAL HEALTH DISTR��'� ENVIRONMENTAL HEALTH DIVISION Job Address 21,Z-t7U' I Vit f1-.GC,kP City 1&0-0TDLot 59% Owner's Name y f U cf +C c Address P.(J. ilU f7_ff--qC3r3 one,/ m G Phone�!5-7?-- I<41--( -7I< S--( (om) Contractor 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 IU �'f• FOUNDATION Iv+. Fr1' AGRICULTURE WELL OTHER WELL!r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation ctrl Dia. of Well Casing I Domestic/Private Gravel Pack ElTracy Type of Casing FlftCl ft` Specifications M Public � I-1 Other I (D Delta Depth of Grout Seal 1E Type of Grout I I Irrigation 7,V+r-Approx. Depth I I Eastern Surface Seal Installed by I('He _ Repair Work Done - ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION LI DESTRUCTION E I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial— Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to'nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth R Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 - i 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 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." Contractors hiring or subcontracting 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 corn ensa- tion laws of California." I SAN JOAQU!N LOCAL HEALTH DISi?gIOT The applica t call far quired inspections. Complete drawing on reverse side. ENVIRONMENTAL 4� HEALTH DIVISION Signed X C�iU1G�� Title: 1Zf�f%C i Q12A,t T fI �Y/J I,fl i/ to Pi jIN y 17 l�f du FOR DEPARTMENT USE ONLY Application Accepted by LDate Area J Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 © Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. .Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE _ AMOUNT REMITTED CCK st.) RECEIVED BY DATE PERMIT'NO. INFO ,p ♦ EH 13-24(REV.ti R5) I� _ -3 Eq 1 _ ,� EH 14-26 �'1 `r0 r { 1 M