90-1910 - Laserfiche WebLink

Home Browse Search

,N APPLICATION FOR PERMIT ;'SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .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.1W2 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District. Job Address City Lot Size PM Owner's Name �I Address Phone E Contractor Address ' License filo.�Phone TYPE OF WELL/PUMP: NEW WELL❑ 'WELL REPLACEMENT 71 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR-Or- OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �,RICULTURE 1N.ELL_ OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation' Dia. of Well Casing �omestic/Private ❑ Gravel Pack ❑ Tracy Type of_Cdsing" Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout — I I Irrigation _--Approx Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done - e Wel! Destruction EJ ' Well Diameter Sealing Material (top 50'1 " Depth Filler Material (Below 50') J -- TYPE OF SEPTIC WORK: NFW INSTALLATION I] REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted-if public sewer is f, available within 200 feet.) 0 \ Installation.will_serve:-,.,Residence.—Commercial_--�.„.-Other.- --- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth s' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal O Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Sm IIIIIIIIN Aft 111110, 6 MOM 1% FILTER BED ❑ Distance to nearest: Well Foundation Property Line 14 SEEPAGE PITS i I Depth Size Number I II I 7 0 19M ` -"z.-SUMPS ' ❑ L)istance to nearest: - ell�Foundation _Property..Li r_..,. DISPOSAL PONDS 171 `�NVMMENTAL HEA�Tt hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Xtqmhil, and 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 perso ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio ing: '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 a } The applicant call for all required i s ctions. Co late rawing on ver 'de. I ' � Signed X Title: Date: F / FOR EPARTME SE ONLY / Application Accepted by Date d Area ` Pit or Grout Inspection by Date Final Inspection by-- Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16d1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE_„--AMOUNT DUE--- AMOUNT.-REMITTED— �CK RECEIVED BY � DATE PERMITNO. INFO CASH + EH13-24(REV.1 i H s) EH 14-28