90-1114 - Laserfiche WebLink

Home Browse Search

a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT ! 1601 E. HAZEL T ON AVE., STOCKTON, CA J Telephone (209) 466-6781 .1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. .il Job Address L2792 W- filtPt/MV City Lott Sze j �jr9C,i?. S PM Owner's Name L WA _ fix _ Address V�— f Contractor rAIJ..MGFP W& 4& -'Addres D2S, icense No. Phone — TYPE OF WELL/PUMP: NEW WELL^ WELL EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ _ ,SYSTEM REPAIR.,❑ _OTHER.❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP LINE r' -FOUNDATkOW,= " AGRIGUL-TURE-WELL-�"'' =OTHER WELIr. P.ITS/-SUMPS INTENDED USE TYPE OF'�WELL PROBLEM AREA CONSTRUCTIOWSPECIFICATIONS ., ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ,DomesticlPrivate *Gravel Pack Tracy W Type of Casing C- Specifications f7 Public ❑ Other 7� F1 Delta Depth of Grout Seal Type of Grout I I Irrigation 't..Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P, I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted it public sewer is 1 II available ithin 200 feet.) 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'. ❑ I Method of Disposal _ Distance)to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines. Total length/size Foundation FILTER BED ❑ Distance to nearest: Well Property Line �M SEEPAGE PITS ! I Depth �M Size Number i SUMPS ❑;,Distance to nearest: Well Foundation Property Line „T- ,, .' —ter- -- — 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 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-l-shalt-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: " c_ertify that in'lthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. II. 2 The ap c nt for all uiredl inspections. Complete drawing on r rse slid t Signed Title Date: F' FOR DEPARTMENT USE ONLY - Application Accepted b Date Area PP P Y .5 Pit or Grout Inspection by Date j Final Inspection by Date:.tS' 19 !iG � _4.0 ".5 -fo c A746.e / A�-1 ray ca o�,t o�.� a.�gc..e� ,u>�u3r- ra �Ls a_J Additional Cammentsa._(, �=-' _ ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Hefilth Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED B DATE PERMIT NO. INFO CASH ♦.EH 13-24 IREV.t i H 5S E C::) �y '`. H 14-26 `r 1 r ,�'Izr_ Pu ,•�r,4�ICcd . W.�. µop-,.: �t�du�f.