89-1936 - Laserfiche WebLink

Home Browse Search

V 'r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a i `is`ne Q: S` _' (Complete in Triplicate) pp y made to the-San�Joa urn-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. ! ►►4�►.flr4eee.r awJla�ira .fl f —f ZB f{O Job Address w .f tn- City—r t71+ Lot Size PM + Owner's Name l/J rJ Address X2+7. ��. GcIO �,�^ (/r y,R.. tl�{D,t) Phone q – f77 Contractor r ?n x IOrgZIA)rZll dre,s IS ZS e n s e No. Phon,6A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION J� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t *1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing vi ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1r Specifications V• FI Public X Other/n ❑ Delta Depth of Grout Seal /9,6 Type of Graut _QW� I I Irrigation _If,–_Approx.I 1 Depth I I Eastern Surface Seal Installed b + Repair Work Done LJType of PumpH.P. State Work Done_ Well Destruction Well Diameter Sealing Material (top 50') S7, ww�f(riw—_,t Depth 211 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRYADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) �4 Installation will serve: Residence_� Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal + Distance td nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i 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 i 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." 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- tion laws of California." II The applica st call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: IFOR DEPARTMENT USE ONLY Application Accepted by Date /V r Pit or Grout Inspection by Date Final Inspection b data Additional Comments: f ❑ 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 G SH RECEIVED BY DATE PERMIT NO. ♦.EH 13-24iREV.iin5f S ✓—s' FH 14-26