90-490 - Laserfiche WebLink

Home Browse Search

I 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. 1862 for welilpump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address �' City ` Lot Size PM I / - Owner's Name dAddress Phone Contractor �,��,s,,< v�Sd fS Address /fes( /�S_0 �SZof License No. ZS43*43 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE,; NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS ♦, ❑ Industria'(` ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing °,Specifications ❑ Public r h Other _fwl_Delta,,, .Depth of.Grout Seal _ 'Type of Grout I I Irrigation } _Approx. Depth ,I l Eastern Surface Seal Installed by _ fRepair Work Done ❑ Type of Pump I H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 F I Depth Filler Material (Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION 1 I DESTRUCTION I o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other __ _ �_e -717T Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT,•,❑ Method of Disposal `z Distance to nearest: Well Foundation Property Line h, 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_ 4SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. t 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 fallowing: "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." The applicant must c or all required pections. Complete drawing on reverse side. Signed / Title: QSfln Date: FOR DEPARTMENT USE ONLY g i Application Accepted by Date 3 r 6 A ea I i i Pit or Grout Inspection by / L Date Final Inspection by a Date k Additional Comments: �dy n1J%f f ❑ Stk 466-6781 ❑ Lodi—%69-3621 ❑ 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 FEf7 \` INFO AMOUNT DUI AMOUNT REMITTED CASH RECEIVED BY ` PATE PERMIT NO. J' +.EH 13-24(REV.1iN5) O O . EH 14-28 - I _