89-457 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �icc) Wi Telephone {209} 466-6781 No PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ ��\ ^ $tLt (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. I Job Address S . P6 k-�(.'— 1- City C Lot Size PM Owner's Name C �� a72 _ l—p 1,& Address 7� Phone 1� / I -�� / llJ Fra r� Contractor Address ` License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL-. OTHER WELL- P! S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ❑ Industrial ❑ Open Bottom ❑ Manteca Dia xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-7 Public f--1 Other to Depth of Grout Seal Type of Grout _ I I Irrigation --.Approx. i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 4 Well Destruction., ❑ Well Diameter Sealing Material (top 501 Depths Filler Material (Below 501 TYPE OF-SEPTIC-WORK:' ,NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION fhl'INo septic system permitted if public sewer is s{� ai • a available within 200 feet.) Installation will serve: "Residence_ Commercial Other Number of living units: Number of bedrooms -- F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity t No. Compartments PKG. TREATMENT PLT. ❑ -- y 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 { 4 SEEPAGE PITS i I Depth Size _ Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l 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 Dietrict. 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 m call for all requiraSWnspecti ons. Complete drawing on rev a si9, ` Signed X Title: "; Date: p ffloBJDERARTMENT USE ONLY Application Accepted by F Date ``" lJ l Area C� Pit or Grout Inspection by Date Final Inspection by Date—13 / 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 CK it INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERRMIT'NNOO./7 +.EH1324 TREY.1 i n 5) 35 r`-"- /' EH 14-29 r� i 1