89-1258 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601. E. HAZEL i ON AVE., STOCKTON, CA l r Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) p �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 ' 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 Z City, - Lot Size— PM Owner's Name, Address /Gwl34 Phone ...Contractor u � AddresS 7 � - License No.3Z 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 FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications ❑ Public C) Other F1 Delta Depth of Grout Seal Type of Grout _ I'I Irrigation __ ..App Depth I I Eastern Surface Seal Installed;by Repair Work Done ❑ T of Pump H.P. ; State Work Done_ 0 Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ex Commercial_ Other r Number of living units: I Number of bedrooms 2- Character of soil to a depth of 3 feet: 1_�� Water table depth `p a SEPTIC TANK 2�1" Type/Mfg Capacity d?pa No. Compartments 2 t PKG. TREATMENT PLT. ❑ Method of Disposal � ` Distance to nearest: Well o — Foundation d 'r Property-Line LEACHING LINE L No. & Length of lines Total length/size W47 Z FILTER BED ❑ Distance to nearest: Well I_013 Foundation Q' r Property Line PAGE.PITS [ I Depth Size t /r f / Number SU PS LA_ Distance to nearest: Well 1�p�f Foundation lam' � Property Line s DISPOSAL PONDS ❑ I hereby certify that 1 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 mus ec'II for all required ctions. Complete drawing on reverse side. y Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Area / 2— //�� Pity rout na(�Ction by 0.to �r�T Fina! Inspection by :11�Z2ZeZr,,1afe Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 d�f i 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 RECEIVED BY DATE PERMIT NO. INFO CASHCK r.EH1324 IREV.f H 5] EH 14-28 c O