89-1051 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Orrinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -JVF _ �� / / A Job Address 40T.� W LIIC.�QS , _.,". City t-1040,1* Lot Size PM' i Owner's Name JOQN L2IK�)O AAFM Address 3,40" Phone ` D y26 Contractor, !.1 Z/ Gr.) .TS Address/"'O 6!%1? 8 License No r?73 rC' Phone 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 s� L FOUNDATION AGRICULTURE WELL riOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOM SPECIFICATIONS $ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weill Excavation Z Dia. of Well Casing _ Ni rDomestic/Private J< Gravel Pack,__ -❑ Tracy. Type of Casing . /n �/G � Specifications r- 1 f'1 Public - , .__n Other ❑ Delta Depth of Gioui=Seal S O Type of Grout -... r - I I Irrigation 'LO-D.-Approx. Depth I I Eastern urface Seal Installed by A .IL Repair Work Done ❑ Type ofPump {t H.P. State Work Done _ Well Destruction t ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION.i I ,REPAIR/ADDITION i I DESTRUCTION I I INo septic stem permitted if p y p public sewer is , ° available within 200 feet.) Installation will.serve: Residence— Commercial i Other Number of living units: Number of bedioomsf Character of soil to a depth of 3 feet:'-"'"""""`' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal ; Distance to nearest: Well "` Foundation - -"v Property Line I' LEACHING LINE ❑ No. & Length of lines "Total length/size i L� FILTER BED t ❑ Distance to nearest: Well Foundation - Property Line r t► SEEPAGE PITS4 I I Depth Size _ Number SUMPS L] Distance to neatest: Well v`.4 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-Di%trict. - -- - �, """ ' - --• -w_:.j Home gWrier 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 all re uired inspections. Complete drawing on reverse side. Signed X ' Title: th AM P, Date: .7-/0-t9 FOR DEPARTMENT USE ONLY Application Accepted by p Data J Area Pit or Grout Inspectio_,by Date_ /9; L Final Inspection by Date It Additional Comments: IF- la ue (gyp,-. I ❑ Stk 466-6781 s ❑ 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 952q].�� j ~INFO'FEE AMOUNT DUE � AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO, /} i EH 14-2a EH 13-24 IREV.$/145)1 /H 51 . ` '\ I /Cf / /"V 111