90-1198 - Laserfiche WebLink

Home Browse Search

APPLICATION'-FOR PERMIT vo AN JOAQUIN LOCAL HEALTH DISTRICT �S 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone {209) 466-6781 MAY 16 1000 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I {Complete in Triplicate) ENVIRONMENTAL� HEALTH �it � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wolep�roLG.%is application 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 City O `�13T Sire PM Owner's Name Address Phone Contractor tcz, 2. Address < �� License NoContractor IQ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION )3 SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 171Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`l Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ Irrigation ' _..Approx. Depjh I Eastern Surface Seal Installed by - Repair Work Done IX Type of Pump f� 4H.P. ' State Work Donee G Well Destruction IDWell Diameter Sealing Material (to 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION ( I, DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet..-I + Installation will serve: Residence_ Commercial— Other i 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance-to neatest: Well Foundation .Property Line LEACHING LINE LlNo.�& Length'of lines f Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ! I ,Depth Size �` _ (Number SUMPS CTS Distance to nearest:' Well " ~Foundation Property Line DISPOSAL PONDS ❑ jwFy 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." b Home owner or licensed agent's signature certifies the following%"I certify that"in the performance of the work'forwhichthis 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 applican call for all required i spection y1tomplete drawir),g-on reverse side. Signed1Tit e: PK;2 t Date: �Z,� T OR DEPARTMENT USE ONLY ;Z/ Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by CU Date i Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 I . Applicant - Return all copies to: Environmental r Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT,REMITTED CK RECEIVED BY DATE PERMI7'NO. INFO CASH + EH 1324(REV. /n 5117 P —Al`i g- EH 14.26 k