89-1820 - Laserfiche WebLink

Home Browse Search

AV APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he)eby 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 A_3Y1 � Lot Size J�•� de_-?&�PM Owner's Name � q �+ _ � .... �_>bl"02, Address �,z� C �nr Phone z_1�4 Contract Address ,71, 7 License No.„�a�r >� PhoneJO.,filoor TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEM ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC URE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO§ AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation ppr1ox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ ype of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ,n Depth Filler Material (Below 50'1 _ V , TYPE F SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION I I DESTRUCTION I l (No septic system permitted if public sewer is J available within 200 feet.) --- Installation will serve: Residence-X, Commercial_ Other Number of-living units: —,I-- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth CJ SEPTIC TANK 09" Type/Mfg Capacity.14d�� No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest. Well Foundation� Property Line LEACHING LINE No. &Length of lines 712 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation_LQ7[,t-Property Line SEEPAGE PITS Depth _SineNumber SUMPS ❑ Distance to nearest: Well Foundation Property Line_ TT 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. Homezwner..or licensed.agent'sstionature certifies the following: "I certify that in the performance of the work for which this permit is iw _(sheI1n9L 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 mu II for all required ' spections. Complete drawing on reverse side. Signed X Title: ' Date: 7- Z- 5F-,?,9FOR DEPAR MENT USE ONLY / Application Accepted by Date 3 ( ( ., Area Pit or Grout Inspection by to Final Inspection by Date 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 PERMIT NO. INFO CASH +.EH 1324(REV.I/a 5) EH 14-26 r. 6