89-2006 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR-PERMIT `- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ! (Complete in Triplicate) i 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 l 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 City Lot Size PM Owner's Name �A' C Address _ So , _ Phone 4 Contractor I'F �� Address tL47�y &4-14T License No. W Phone q:5%568 ' f 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom❑ El Manteca Dia. of Well Excavation + Dia. of Well Casing Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications M Public [I Other F1 Delta Depth of Grout Seal I I Irrigation A Type of Grout ., —.- pprox. Depth 11 Eastern Surface Seal Installed by Repair Work Done Type of Pump, !rE H P f' tt State Work Done i Well Destruction ❑ Well Diameter f Sealing Maferial (top 50') I -�� Depth Filler Material (Below 50'}�` ' ' "•'i" ' +`—��—'�� ' TYPE OF SEPTIC WORK: NEW INSTALLATION I.1. REPAIR/ADDITION L] DESTRUCTION I I (N'6 septic system permitted if public sewer is avAjlable within 200 feet.) Installation will serve: Residence, Commercials Other `" . r ,_� �. 7� Number of living units: Number of bedrooms i't Character of sail to a depth of 3 feet: .- Water tabl&depth : SEPTIC TANK ❑ Type/Mfg I t*' � ��' ?' Capacity p Y No. Compartments PKC. TREATMENT PLT. ❑ ^- - - " Method of Disposal i , 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 i li SEEPAGE PITS I 1 Depth 1 Size _ Number SUMPS Ll Distance to nearest: Well .Foundation i 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. 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 k 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 tion laws of California." P P Y Persons subject to workman's compensa- tion applicant m_usQt call for all required�ins�pections. Complete drawing A reverse side. ; Signed ]< " G -+-�J�^� Title: # ;� Date: F.0 DEPARTMENT USE ONLY G Application Accepted by " Date v —�� I �® t 1 Area y Pit or Grout Inspection by Date Additional Comments: Final Inspection by Dat; / ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmeh tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 s FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.t i s 51 3� �� 'D1 EH 14-26 (J I{p O a 7d