90-668 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED L (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- n<1� /1-% — City `r tot Size PM I Job Address e p 1/P J C�1�G_ Address tz"� Owner's Name, Phone ; Contractor Address License No.(� Phone V �� - TYPE OF WELL/PUMP: NEW WELL I! WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR .� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMP5 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Dia. of Well Casing 'r Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing Specifications aType of Grout [`1 Public ❑ Other (-1 Delta Depth of Grout Seal I I Irrigation _.-App(ox. Depth {1 1 Eastern Surface Seal Installed by - Repair Work Done l�Y Type of Pump H.P. 5 State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth Filler Material IBelow 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is � ` t� available within 200 feet.) Installation will se e: Residencet�*– Commercial` `Other"' F`- - 4 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 ` PKG. TREATMENT PLT. Ll of Disposal (vim Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El hereby certify that I have prepared this applicatign and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r rules and regulations of;the San Joaquin Local'Heaith 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 person in such manner as to become subject to workman's compensation laws of California."Contractor's(tiring 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 com ensa- tion laws of California." s The applic us call for all requir q spect' s. Com to drawing on reverse side. Signed X r �� Title: Date: _ _�� S FO €PARTMENT USE ONLY r } 1 lb Application Accepted by Date t Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: C] Stk 466-6781' ElLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835=6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 1 'FEE AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24IREV.i/si51INF �EH 14-28