90-1220 - Laserfiche WebLink

Home Browse Search

APPLICATIONFOR PERMIT D O SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 �1 + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y 1 (Complete in Triplicate) �-�-793 Z Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thispplicarion 1s 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. �� Grp rte - 1- f Job Address 4(/ U :k?-�,-> ( City tot Size PM ' Owner's Name 4 '`►'t- � - Addres / Phone Contractor Address License No. 1�3Phone_ TYPE OF WELL/PUMP: - NEW WELL 2- 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [r F] Industrial f ❑ Open Bottom ` �` El Manteca pia. of Well ExcavationDia:of Well Casing P-Domestic/;Private CIGravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other A €l Delta Depth of Grout Seat f' r Type of Grout��*� I I I Irrigation A/ QjApprox. De th ' { I Eastern Su ce Seal Installed by --?�L/` Repair Work Done ❑ Type of Pump State Work Done Well De ruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 RFPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is -� f available within 200.feet.l Installationwillserve: Residence�� Commercial " Other 3 W Number of living units: Number of bedrooms.— Character edrooms.Character of soil to a depth of 3 feet: Water table depth } SEPTIC TANK ❑' Type/Mfg Capacity ! No:Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS] I I Depth. Size Number SUMPS CI Distance to nearest: Well Foundation Property Line ' ' 1 DISPOSAL PONDS ❑ i$ 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(Z rules and regulations of the San Joaquin Local Health District. It Home owner or licensed agent's signature certifies the following: "1 certify that in the perforrnance 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 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 must call for all required inspections. Complete drawing on reverse side. Signed XDate: /rte -J itte: J w „ OR DEPARTMENT USE ONLY p I , i Applic ccepted by a Date 5y-��-� l_ Area 1 PI or Grout nspection b � Dates'ES _ - ) Final Inspection b 1' ` Date' �r A al Comments: /3 t.4 r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma taco 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 CK V INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT7NO. �-to uo� +,EH 13-24(8 EV.i/&5) Sd ?i`v EH 14-29 -