90-1819 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r. 1601 E..HAZ-E�T,61 \XV�E., STOCKTON, CA Y eel phone (2091486-6781 . 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 appficataquin 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 r Local Health District. PM I �^� Q l r Cit Size Job Address Address Phone tnsfiallatlon wlfl ser ��l�� a�� ••---- �--��,„�,��j - `-' I mote471 Other ------------------------- ` _ ---- k ` ' -- r -- acre --- -------- cre ' TYPE OF WELL-/PUMP: =-----1�fE 'WELL �"'-� 'tNEtL-REPLACEMENT - -,: _ _. ih SYSTEM REPAIR ❑ OTjiER 0_ - ` s PUMP INSTALLATION 9 DISTANCE,TO NEAREST: SEPTIC TANK a ">♦ SEWER LINES DISPOSAL FLD.,nOf PROP. LINE -' FOUNDATION _.jQ�- AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI ❑��Industrial ❑ik0 en Bottom ❑ Manteca Dia. of Well Excavation = Dia. of Well Casing I�DomesticlPrivate L 'Gravel Pack Q Tracy Type of Casing G � Specifications tp it Public { ❑p Other ❑-Delta's'-'" "'Depth#of Grout Seai Type f Grout - F I 1 Irrigation —4 -Approx. Depth It I Eastern Surface Seal Installed by i St Work,Done Repair Work Dane ❑ Type of Pump i Well Destruction r Well Diameter Sealing MateriaE':Ga4`•1- Depth yi ) TYPE OF SEPTIC WORK: NEW INSTALLATION!1.1 REPAIR/ADDITION MDESTRUCTION-1 I (No septic system permitted if pLiblicse�wer is SJ 4 I available within 200 feet.) •I. Residence t Installation will serve: Re�idents, Commercial--Other'--"'^'"4 F Number of living units: Number-df bedrooms • t �� _ Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg ' _ Capacity No Compartments PKG. TREATMENT:PLT. ❑ ', Method of Disposal_ r r .. r I Distance to nearest: Weh Foundation # Property LineIk - �, 1 Total len e 7 f LEACHING LINE r U. No. &�ength.pf lines. th/siz g FILTER BED ❑ Distance to nearest: Well Foundation Property Line,� 1 V f SEEPAGE PITS � l I l Depth'- Number I SUMPS Lii Distance to nearest: Well Foundation Property Dine a DISPOSAL PONDS ❑',: 4N hereby certify that I have prepared this application and that the work^wJll,be done in accordance with San Joaquin county ordinances, state laws, and rules and regulation e� oaquin Local Health District. 4 /r t } Home owner or I' nsed agent's si nature certifies the following: "I certify that in.the performance of ttie work for which this permit is issued, I shall not employ any pe oniin such manner s to be me subje orkman's cam ensation laws of California." Contractor's hiring or sub-contracting signature certifies the f lowing: '9 certif h in a or a e of . e w r which this permii iis,issued,I shall employ persons subject to workman's compensa- } tion laws of Cafifor ia, I' ate : S The applic nt c all req 'a orn drawing r id / Title: �/"" -"� Date: _ Signed X tt t EPARTMIENT USE ONLY " r Application Accepted by Date T1 , Area Pit or Grout Inspection by f5ate Final knspection by "�✓--�� DatQ Additional Comments: I'^ r o l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385rn�� Applicant- Return all copigs toi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241�v � FEE AMOUNT DUE AMOUNT REMITTED C SH, RECEIVED BY GATE PERMIT-NO. 11`0-t O INFO ♦.EH 13-24 MEV.I/H 51 r EH 1448