90-3243 - Laserfiche WebLink

Home Browse Search

A3APPLICATION f P&MIT SA�N JOAQUIN LOCAL HEALTH C!!MICT Y\� 16011 E. HAZEL T ONAVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES T 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.Thls application is made in compliance with Son 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. Job Address city City .Lot Size- PM Owner's Name dress Phone 7ZContractor Address Lp / k/V License No. _Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravfd',Pack ❑ Tracy ;.Type of Casing Specifications rl Public n Other ' n Delta Depth of Grout Seal Type of Grout I I Irrigation __Apepbi ' . Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dorm + + -Udell DestrttGtial Well Diaeter- Sealingng Material ltop;50'l ^ –" mSealingdj .i Depth Filler Material l8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available Within 200'feet4 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE ❑ No.B Length of lines Total,length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - I hereby certify that f 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 Dilitrict. ��}}}} „ 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, 1 shall employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signa certifies the following:"I certify that in the performance b`#w work;for which this permit is issued,I shall employ persons subject to workman's co rise- tion laws of California." The applicant call ail r (red inns:;Comp o&awi rev side. Signed Title: L Date: J 2,h_0 A-*,* FOR QI PARTNI&T USE ONLY `. f Application Accepted by 1. � Date Area �t Pit or Grout Inspection by Date _ Final.(maec*m :.� to�' 7- -Additional Comments ❑ Stk 466-6781 O Lodi 36.9-3621 ❑ Manteca 823-7104 O°Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.Q..Sox 2f109, Stk., CA 9MI FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH VEO BY DATE PERMIT'NO. �. EH 11.EH 14.26 21 1REV.1/"51 ( �J!