90-1200 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781Y IS 1990 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ENMIMMENMHEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wE"�C'h", �i�crtf This apptication 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. ! Job Address �R ��`--l------ S J f — CitO I at Size PM Owner's NamAddress S �+�-!`� Phone I ContractorAddress + License No�J2—Phone TYPE OF WELL/PUMP: NEW WELL` ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 5�- 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 i ❑ Industrial ❑ Open Bottom \Cl Manteca Dia. of Well Excavation Dia. of Wel! Casing Domestic/Private ❑ Gravel Pack ❑ Tracy T -� Specifications 1`7 Public 1-1 Other F7 Delta S Type th of Grout Seal ype o Casing � p �� Type of Grout I I IrrigationApprox. Depth I Eastern _ Surface Seal Installed by"' _ _. Repair Work Done F ' Ty-pe of Pump ti.P. T m �"�- �� ' � - State Work bone Well Destruction ❑ Well Diameter Sealing Material (tap 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR-/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) (n Installation will serve: Residence_ Commercial'_ Other J Number of living units: Number of bedrooms t 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 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS p ; 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." -- The applicant call for all required inspections omplete drawing on'r� arse side. Signed ,Title: I Date: 1 r FOR E RTMENT USE ONLY Application Accepted by Date Area �< Pit or Grout Inspection by Date � - Final Inspect.ion by_ JG.�tC_�.�� pate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621`i j ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return 811 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-CA 95201 FEE AMOUNT DUE AMOUNT REMITTEE) 4 INFO CASH RECEIVED BY DATE PERMIT`NQ. 11 t.EH T3-24 iREV.I/R 5) .t EH 14-29