90-1208 - Laserfiche WebLink

Home Browse Search

z AI�II r" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �{ 1601 E. HAZEL i ON AVE. STOCKTON, CA I Telephone (209) 466-6781 MAY 1990 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' . (Complete in Triplicate) ENVIMNMENTAL HEALTH PERMIT/SERYJCA� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe is application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the mules and Regulations of the San Joaquin Local Health District. , 2 Job Address [(f v ' s \S City G ---tM Size PM Owner's Name 'S k WCA'AcAddress Phone Contractor T0 Address� � � rlL License No. Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ y DISTANCE TO NEAREST:,SEPTIC TANK—SEWER.LINES DISPOSAL FI_D. PROP. LINE FOUNDATION b AGRICULTURE WELL OTHER WELL PITS/SUMPS a' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing yv� igDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public l I-1 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 '5'aJ9-- H,P, State Work Done Cr es Well Destruction ❑ Well Diameter ti Sealing Material (top 501 'Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is a � available within 200 feet.) LA 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 SEPTIC TANK p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE .❑ No. & Length of lines Total length/size FILTER BED O' Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1,1 Depth Si e Number -M ,- SUMPS •❑ Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS .R . U I 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. Home owner or licensed agent's signature certifies the following: ".1 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: '•'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 mus � r all required inspectio Com to drawing on verse side. a s Signed X c� Title: �'f!�S Date: FOR DEPARTMENT USE ONLY Application Accepted by , Date Area Pit or Grout Inspection byData Final Inspection by Date I / Additional Comments:, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2(X19, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 41 RECEIVED BY INFO CASH DATE PERMIT'NO. J r.EH 1 -I41REV.tiK51 -s 1 EH 144-26