89-383 - Laserfiche WebLink

Home Browse Search

,. APPLICATION FOR PERMIT old .t o I` a'- I''GLv4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON; CA _ Telephone (209) 466-6781 � � Z 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. S l M.r. _ Job Address I w i Z City &,el Lot Size. ' Ac- PM IT r V �U "-1 -� S S`1.3 / tr vK�[fox�, r� �baa/ 3 —%6 Owner's Name Address l Phone Contractor � t :.� yF, .it r+1+C f' SdJ+1f' Address '�10VA '� License,No} Phone l,Q TYPE OF WEl_L/PUMP: NEW WELL ❑ WELL REPLACEMENT C. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ _ r -DISTANCE-TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. � PROP. LINE-`�� Y 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 w ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications PI Public 11 ❑ Other FI Delta Depth of Grout Seal Type of Grout _ P l-1 Irrigation _.-Approx. Depth t I Eastern Surface Seal Installed by Repaif Work Done' ❑ Type of Pump H.P. State,Work Done_ Well Destruction'' ❑ Well Diameter Sealing Material {top 501 f s Depth Filler Material (Below 541 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓� Commercial Other Number of living units: —[-__ Number of bedrooms * Character of soil to a depth of 3 feet: �Ok Water table''depth SEPTIC TANK Or Type/Mfg Capacity /,a2 No. Compartments -Z- PKG. TREATMENT PLT. ❑ Method of Disp sal ... ''7 Distance to nearest: Well 00 � Foundation f O Property Line `� 40 "t b t LEACHING LINE LST No. & Length of lines yA _ Total length/size p FILTER BED '❑ Distance to nearest: Wella� Foundation &29 Property Line 3��"f r i , SEEPAGE PITS 03�'Depth Size�� --Number SUMPS. ❑ Distance to nearest: 7 Weil Foundation`.E` _._= Property,Lme.. 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. ° �� # �:•it Home owner or licensed agent's signature certifies theJotlowing:-,'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 required inspections. Complete drawing on reverse side. Signed X�.�r-RA. Title: �!< -` .7 v? _ Date: R DEPARTMENT USE ONLY ` -Application Accepted by SEFO Date �� ' Areaf r Grout Inspectio / '� F nspection iv �. `�faz¢ Data 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1/n 51 EH 14-26 �/ "� >