89-2283 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address fj-5 7�9�� _1 _ City f' Lot Size PM '� Phone .Owner's Name �Address Contractor �� ill Address r 'an D�. (aff_17r_License Noq9q.3%a Phone-3'7-; I i TYPE OF WELL/PUMP: NEW WELL>7 WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTA_LLATION,*. SYSTEM REPAIR 0 OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TAW�1 OC?_I SEWER LINES DISPOSAL FLD. Y PROP. LINE } FOUNDATION `AGRICULTURE WELL�� OTHER WELL PITS/SUMPS A470 J i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ) i C7 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �y omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ��'�� _ Specifications O I;1 Public ❑ Other 71 Delta Depth of Grout Seal Q Type GroutL�� ''L '- 1 f I Irrigation a-.49-Approx. Depth l I Eastern $ ace Seal Installed by e Repair Work Done ❑ Type of Pump H.P. ! State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth - Filler Material Melow 501 , TYPE OF SEPTIC'WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) 'Installation will serve: Residence— Commercial— Other Number,of living units: Number of bedrooms 1 :Character of'soil,to_ a`depth of 3 feet: Water table depth .SEPTIC-TANK. Ft -D=Type/Mfg Capacity No. Compartments -IPKG. TREATMENT PLT. ❑ Method of Disposal S s ? {j am Distance ib-nearest: Well I° Foundation Property Line-_—__ BLEACHING LINE L1 No. & Length of line, - Total length/size { FILTER BED- l ❑ Distance to nearest: Well "" Foundation Property Line SEEPAGE PITS I ! Depth Size' Number'iSUMPS L-i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ /f 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 Dibtrict. 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, 1 shall employ persons subject to workman's compensa- fion laws of California." The applicant-must call for all required inspections. Complete drawing on reverse side. I R -'-'Tiffs: _ �,r_. .�... __, D'a'te:- - -i - - i 1 FOR DEPARTMENT USE ONLY i ! 2 Application Accepted by Date � Area C� � Pit or ro t Inspection by��`/ /�� date Final Inspection by ate 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 I FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. INFO CASH -_ - r.EH 13-24{REV.r/A51 EH 14.26 L `