89-665 - Laserfiche WebLink

Home Browse Search

" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)41111II&N74Lf ' 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. li City Lot Size _�-00 /t / PM Job Address 72 ��GL Address 0 Phone %J— 4 Owner's Nam�y �f r f ,Sa Contractor Sal t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE T T:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL LEM AREA CONSTRUCTION S S 13 Industrial ❑ Open Bottom LlManteca ell Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack cy ��Type sing Specifications M Public er ❑ Delta-.--r Depth of Grout a Type of Grout _. I I irrigatio Approx Depth i-I`Eastem Surface Seal installed by a Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter 3 Sealing Material {top 50'} Depth A Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DLSTRUCTION t p INo septic system permitted if public sewer is available within 200 feet-i Installation will serve: Residence Commercial_ Other 11 Number of living units: Num r o Character of soil to a depth of 3 fee . Water table depth t SEPTIC TANK ❑ Type/Mfg apoi No. Compartments PKG. TREATMENT PLT. ❑ . ! Permit may have expired without Method of Disposal t Distance+� r SL.�I�r,W 6�lett! F&;�a�n�— Property Line LEACHING LINE ❑ No. & Len yo...ir�yjron r t{Ial Ref n 1 Y Total length/size FILTER BED ❑ Distance.;ta.nearest: Well Foundation Property Line i � I SEEPAGE PITS l I Depth I 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 rules and regulations of the San Joaquin Local Health Diltrict. 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 I 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." I The applicant must call for all required inspections. Cate drawing on reverse side. Signed X Title: Date: a t FOR DEPARTMENT USE ONLY s Application Accepted by Date Area Pit or Grout Irispectio y Date Final Inspection by Date i , 1 Additional Comments: 2' L/ J � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 623 7104 ❑ Tracy 835-mf t Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO- / INFO CASH f µ +.EH13-244REV.tirt5f �� i�! �f.l'y r• 7 U U ! EH 14-26