89-2776 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUfN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Rk E C E I V E ug' Telephone (209) 466-6781 NOV ' ��8� PERMIT EXPIRES f'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereP,4M Ti1SE i l&n 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 22(e q 9 Lt City Lot Size PM Owner`s Name ^' ess �7� /�—t r—t7�� Phone 7c Q Contractor!�-C�i - � _ Address 6 Y6 .d License No.&_2=l 23 Phone —96 5.r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �'SEWER LINES DISPOSAL FLD. 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 LfiDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ r I I Irrigation Approx. Oeptq Eastern, Surfafe Seal Installed by: _ Repair Work Done L�f' Type of Pump �H:P. 1 ��_ State Work Done Well Destruction C Well Diameter ' Sealing Material (top 50') Depth Filler-Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (1 -REPAIA/-ADDI,TION l I DESTRUCTION ( I (No septic system permitted if public sewer is 6' — --— ( „ available within 200 feet) Installation will serve: Residence_ Commercial" 'Other w, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS 17 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. 1, 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 applica must call for all req ired inspections. Complete drawing o reverse side. P Signed X _._ "`title: —- _ Date: vq•�" FOR DEPARTMENT USE ONLY x / Application Accepted by Date / -__ Area r Pit or Grout Inspection by Date Final Inspection by d// �te a4rt�? Additional Comments: ID 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY 5 - DATE PERMIT'NO. EEH 3 24 H 14 26 IpEV.1/8 51