90-1797 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 RECEIVED PERMIT EXPfRES 1 YEAR FROM DATE ISSUED JUL } f (Complete in Triplicate) ENVIRON . NV+ p �A 7 {H,� A� Application is hereby made to the San`Joaquin.Loc4I.Health District for a permit to Construct and/or install the �OtYrr` �iA��"T -W � �QS tion is ` made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the u gu��l ��San Joaquin Local Health District, Job Address City Lot Size PM — Owner's NameAddress Phone t� r r 3 ,Contra ctokil Yd Address License Nv. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP-INSTALLATION-0 SYSTEM-REPAIR�K OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL Fl D. PROP. LINE FOUNDATION _AGRICULTURE.WELL.__' .OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,,D❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public f_1 Other ❑ pelta Depth of Grout Seal T ' ype of Grout _ I I Irrigation l �.Approx. Depth I I Eastern• Surface Seal Installed by _ . Repair Work Done ❑ Type of Pump H-P. ' State Work one ^ t Well Destruction IDWell Diameter DD " Sealing Materia! (top 501 Depth 42'C2 Filler Material (Below 501 • d l� TYPE OF,SEPTIC WORK: NEW INSTALLATION 1.1 ,REPAIR/ADDITION i I DESTRUCTION i I Wo septic system permitted if public sewer is s Y t Installation will serve: available within 200 feet.)Residence� Commercial� Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth R-- i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal = { Distance to nearest: Well Foundation Property Line LEACHING,LINE ❑ No. 8r Length of lines Total length/size r FILTER BED ❑ Distance tonearest j well � Foundation Property Line SEEPAGE�PITS i 1I Depth�`�'�-� Size Number 1l SUMPS f. C Distance to nearest: Well Foundation �.aDISPOSAL'�PONDS 1 —[1 ,..�:.a� x��F w__ _. ... ^-.. Property Lin I hereby certify that Ishave prepared this application andihat t)ie work will-ba done in accordance with San Joaquin county ordinances, state laws, and �T rules and-regulations of the San Joaquin Local Health District. l 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 laws of California."Contractor's hiring or sub-contracting signature certifies the folio 'ng: "1 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 6i Ca rfo nia." The appl" ant t call for a fired inspe n Complete drawing r e se4�, ff Signed X t Title: Date: - - r i F R D f ARTME T USE ONLY ! _Application Accepted by Date,� b Area Pit or Grout Inspection by .-- Date # T 1 Final Inspection by Data / .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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i, FEE CK INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE EPERMND.( CASH+-EH 1324(REV.r i B slEH 14-26 ^