89-1025 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YE-6 FROM DATE ISSUED (Completehn Triplicate) Application is hereby made to the San Joaquin Local Health District for ahermit 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 i Local Health District, I I i Joh Address - City Q�L!P Lot Size PM Owner's Name - Address 3 I�3 ��- Phone e Contractor � AddressLicese No.Jt Phone �7 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL AEPLACEMENT;. Nr, DESTRUCTION ` . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ��O�{{TyyH,,.E((R ❑ DISTANCE TO NEAREST: SEPTIC TANK _ 17 SEWER LINES DISPOSAL FLD.1Y�_._ PROP. LINE -,-FOUNDATION AGRICULTURE: ELL`" OTHER WELL PITS/SUMPS INTENDED USE ,`� ,,TYPE OF WELL PRPR SA CONSTRUCTION SPECIFICATI S � E] Industrial ❑ Open BottomManteca Dial. of Well Excavationk Dia. of Well Casing �y �} Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ��jv P'f�� F] Public Other ❑ Delta Depth of Grout Seal 0 Type of Grout I I irrigation —..Approx. Depth I Eastern Surface Seal Installed by,_1Llsie1 P� Repair Work Done ❑ Type of Pump H.P. I�' tate Work Done.01 _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 400/Com 62 - Depth 4W Filler Material V(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONl I DESTRUCTION I 1 14o,se ti tem permitted if public sewer is VII (I Installation will serve: Residence_ Commercial_ Other .11. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V t SEPTIC TANK LJType/Mfg �� Capacity .2om�ri�lts ' PKG. TREATMENT PLT. ❑ y I� R Method of Disposal Distance to nearest: Well Foundation �t�dberyNJt � LEACHING LINE ❑ No. & Length of lines !h Total length/size FILTER BED ❑ Distance to nearest: : Well Foundation Property Line I SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation - Property Line y 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. I .y. 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 cornpensation 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 Califor ' The applican ust c II for rlu' d�nsppections. Complete drawing on rev9qe side. �- Signed X Title: > _ __ -_ Date: 5'*1 Lie d - I M • + F. DEPARTMENT USE ONLY 0261 I' _ Application Accepted by Date `5 Area - r Pit or Grout Inspection by Date ' I Final Inspection by Date J Additional Comments: I�I ❑ Stk 466-6781 0 Lodi 369-3621 EI Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO GASH +.EH 13-241pEV.ties" I� F-) 02 EH 14-28 IM