90-1838 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE11 Telephone (209) 466-6781 JUL 7 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH , (Complete'in Triplicate) � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work a �n sc its + pp kation 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 Sari Joaquin Local Health District. City Lot Size PM Job Address �I ��(� _3` Address (fin es � � hone (o Owner's Name / � �!-5t-"'_–,�nn 14 Lscense No.��Phone +� Contractor Address ContraI TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E) k PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ t DISPOSAL'FLD'"" ""#PROP-CINE DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ElOpen Bottom 1-5Manteca` Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing---:x— Specifications 1=} Other ❑ Delta Depth of Grout Seal � Type of Grout F1 Public j i I irrigation �..Approx. Depth [ I Eastern Surface Seal Installed by `� i Repair Work Done ❑ Type of Pump 44�� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I l Depth Filler Material (Below 501 -- ` + OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I 1 DESTRUCTION l 1 (No septic system permitted it pu6lic'sew�r isYµ TYPE -available within-200 feet./ i Installation will serve: Residence— Commercial` Other { t, Number of living units: Number of'bedrooms � / = J _ Character of sail to a depth of 3 feet: Water table depth No. Compartments SEPTIC TANK ❑ Type/Mfg ` Capacity PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well i"Foundatio " n "Property Line I f.. t Total length/size I ` ;LEACHING LINE ❑ No. & Length of lines -- FILTER BED ❑ Distance to nearest: Well f Foundation Property tine Number SEEPAGE PITS I 1 Depth Size _ _ _.. – "SUMPS ❑ Distance to nearest: .r WeH '"'�"" 'Foundation�F Property Line DISPOSAL PONDS ❑ Y r application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and :1 hereby certify that I have prepared this app F 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 r employ any person in such manner as to become subject to workman's compensation laws of Califotnia."Contractor's hiring or sub-contracting signature certifies the fotl g: " ch this permit is issued, I shall employ persons subject to workman's compensa I certify that in the performance of the work for whi M tion laws of Ca for la." i f The appli t - t call for all r wired insliRctions, Complete drawing o re e e side. 11 I ~� Signed X Title: Date: if FOR DEPARTMENT USE ONLY .--Date - – - Area Application Accepted by 4 r I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: G G `l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 ' –. .�--.– FEE "�A" OUNT DUE— "AMOUNT REMITTED) CASH W RECEIVED 9Y DATE PERMIT NO. µ I INFO Y N14s r vim • , y/y�- 9d`83 ..EH 13-241REV.+iH51 r ' r�.r _��_ EH 14-28