90-1812 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT I2091 466-6781 � RECEIVED f lfi [jQtjly'!'Y IT ES YEAR FROM DATE ISSUED APR _ 5 jiMONMBNT CAplete in Triplicate) � $ Application is hel oPq 1 a1ih District fora ermit to construct and/or Inst SAN JOAQUIN CO NT `�Ml11 s application is made in complian It un ounty Ordinance No. 549 for sewage or No. 1862 for wgll/pum� � San Joaquin Local Health District. rt�/ pf}( 111 Job Address _L4331 _�1/�p111� City T'1 Lot Size /pY `� lG 1 PM Owner's Name Chew r p rn VSAr A dress .C- 6 &1.n I� oL++roY1 Phone I942-,?5Z4 Sterna '" V +TOV%r� e_r, P-0C$?-%44(a ReL^ +/�C 1CA � Contractor�i-l S & �OrAA_L0 Address ( Y�iCCtti11� icense No.� rj 9(a Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ��-�}.4 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES p fo G'Co�lit 09A.4 FLD.� PROP. LINE AaLOd-1?rt r FOUNDATION AGR CCULTtURE 1NELL AJIA OTHER WELL APITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationit Dia. of Well Casing ` ❑ Domestic/Private Gravel Pack ❑1T�c � Type of Casing— _ Specifications f�•3\ Fl Public n Other F1 elta Depth of Grout Seal __�' Z b 1 T t ype of Grout rt Q? 1 E�I rrigatioi- _._-Approx. Depth I I Eastern Surface Seal Installed by 1r C' Re alrk. �l (tone� Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 501 __ + TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 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 F\ i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line 1 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 1 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 Datrict. ; "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following 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 must call for all re uired inspections. Complete drawing on reverse side. Signed Xn Title:� � .7f,/ Date:61 FOR DEPARTMENT USE ONLY Application Accepted by Date 40 Area Pit or Grout Inspection by Date Final Inspection by Date .� 90 Additional Comments: LJ63 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY PERMIT NO. 4 INFO H t _ r.EH 1374(REV.I/K51 EH 14-26 jja�: 1 ! y