90-380 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 0 SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1 i 1601 E. HAZE t ON AVE., STOCKTON, CA ill�m Telephone (209) 466-6781 F E B 2 0 PERMIT EXPIRES i YEAR FROM DATE ISSUEft1V1RONMENTAL HEA!TH (Complete in Triplicate) PERMIT/SERMES 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Job Address.) 7 J City / t Size PM _L f57 Owner's NameAddress `�'�• r ±r �- Phone0.4 Contractor io� Address c � License No&�-37_3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION ❑ PUMP INSTALLATION ❑ l SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWFR.LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM ARIEA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2-Domestic/Private ❑ Gravel Pack ❑ Tracy ! Type of Casing Specifications F1 Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout ._ I I Irrigation __-.Approx. Dept l ESurface Seal Installed by - Repair Work Done L3' Type of Pump �astern H.Pi r State Work one Well Destruction ❑ Well Diameter Sealing Material atop 50') LUDepth '. ".... =-- ..-..; —Filler..Material-{•Below-50:)-� --—- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR PADDITION LI DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence_ Commercial— Other r �3 Number of living units: Number of bedrooms j / I Character of soil to a depth of 3 feet: : Water table depth SEPTIC TANK ❑ Type/Mfg fy Capacity No. Compartments PKG. TREATMENT PLT. L1hilethod of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size �I FILTER BED ❑ Distance to nearest: Well Foundation—. Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r ` 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. 3 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." Contractors 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 Ast c I for all r wired inspectio . Complete drawing onreverseside. Signed XrT Title: !✓ �.z Date: O �!_ q t R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by, vzez�1_1-4Date p 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 2005, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT-NO. INFO CASH + EH 1321fREV.i/n5Y � F,� � / EH 14-29 t