90-404 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT -7 SAN JOAQUIN LOCAL HEALTH DISTRICT �7 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �( r/ 0,114 City Lot Size PM t r � Owner's NameX.Z'a�2)19!&A44e Address y� 72J4--Phone Contractor��C �^G Address �- bS3��1� License No.�4#9� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,)� SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ( Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout—.--- i rout _I I Irrigation —__Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done lk Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 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 l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Ni 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 ❑ ;. 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, an4--,', rules and regulations of the San Joaquin Local Health Diltrict. 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant / for all required inspections. Complete drawing on r verse side. t, 9 Signed X " Title: Date: FOR DEPARTMENT USE ONLY /) ® Application Accepted by Date rea �+ r �y Pit or Grout Inspection by _,� Date —..._. Final Inspection by___ {t / Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3(:,i -sct aca _Z23-7104 U 'l iacy 835-68b FEB Z 6 P1 e,)9 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 EM'IRONMENTAL HEALTH FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE I (CES INFO CASH +.EHt10-ZBQ'3-21(REV.1/85) EH *::'_/-_)-7Z ® O_f 1 I O / "