90-3054 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA N Telephone (209) 466-6781 r1r� '" PERMIT EXPIRES TYEAR 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. 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. ob Address 9J7.6; b7 jyd &l. City �Y/4 C S/ Lot Size St4CrCS PM N Owner's Name Address -70709 Phone gid' X309 t 1 Contractor AN/ &M4 5�7/Y Address V002 Jy !N te^f 4&ff License No. y�V J97/ Phone✓`��3�y,?/ 'fir TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 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 t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 1-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by _ 1.1"pair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK:' NEW INSTALLATION 1 ) REPAIR/ADDITION Al DESTRUCTION I 1 (No septic system•permitted if public sewer is available within 200 feet.) t. Installation will serve: Residence 1— Commercial. Other Number of living units: —/_ Number of bedrooms A ;> + Character of soil to a depth of 3 feet: X141 \T Water table depth'x- SEPTIC TANK. — e_Type/Mfg P/ .eOtFrCapacity— 767_ No. Cain_pbrtments1 PK G. TREATMENT PLT. ❑ 'J w e, Method Of Disposal Distance to nearest: Well JCCl V Foundation I Property Line CCG Y LEACHING LINE (CI No. & Length of lines 4 f Total length/size 4f 9`f [ FILTER BED ❑ Distance to nearest: WellUQ `i- z Pro "4' r. 1_ ....____ Foundation Z_ Property Line 1UO s t SEEPAGE PITS•._(.I—Depth_..._.�_-.__ . Size.�� '0 � Number SUMPS Distance to nearest: WellO' g9' Q �..._-Foundation—� Property Line � DISPOSAL PONDS ❑ 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 Di"strict. 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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that'indhe 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 X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l Area a�6 4 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: —fa rQ 4 I ❑ Stk 466-6781 ElLodi 369-3621 ❑ Martfaca a23-7104 ' ❑ Tracy 83S6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE I 41 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. . EH to-24(Rev., H 5) �� J < ��.3 :11ZI6 y0 EH 14-28