90-2189 - Laserfiche WebLink

Home Browse Search

m APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address Q Cit Z"Aof Size PM t r Owner's Name Addres i Phone Contrac Address �67� License N " P LCt Phone `S-�1E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '. w DISTANCE TO NEAREST:.,SEPTIC TANK � ;SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL �- OTHER WELL - PITSISUMPS ` 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - \ Repair Work Done El Type of Pump H.P. State Work Done �� f Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet:).__ r N Installation will serve: Residence Co:b me Bial_ cher /r 1 Number,of living units: � Number of be oms - Character of soil to a depth of 3 feet: - Water_table depth. SEPTIC TANK © Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. Elf'+-�- Method of-Disposal Distance to nearest: Well- `Foundation r T F Property Line LEACHING LINE ❑ No. & Length of lines ` ° + Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS 11 Depth'. Size x X Number f r !s Distance to nearest:-— Wel _Fnundation; c 7O Property Line 4 DISPOSAL PONDS f❑1! 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: "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 l 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 call for all a ire " spections. Complete drawing on reverse si . Signed X Title: Date:ib FOR DEPARTMENT USE ONLY �f(� 3 Application Accep ed by rn 1� Datt� 1/6 ` '" Area • Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-61ill;,t. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant- h6tur�'�' Ar all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f L ' (FEEO AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO, +,EH13-24(REV.I/n 5) Li EH 14-26 F� r