90-37 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN Q 3 1990 (Complete in Triplicate) SAN JOAQUiN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instl ,�� rBW11<nlsspplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump an ��dDI>w&QW Joaquin Local Health District. r Job Address PACE'Pi L &L_ City s Lot Size IZO X 10 PM :21 IS Al. CAL, wa&104WArc.ao af- Owner's Name 00A-L- Address (D Phonp`,�576 ` Contractor P'MAMO '(.Q� Address O AT29DAKl40Licen a No. 25y�Z0 Phan Z `S5� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE �TO�7�SEPTICNK SEWER LINES DISPOSAL FLD. P LINE ON AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE r TYPE OF WELL BLEM AREA CONSTRUCTION SP TIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Casing Specifications * Public is Other to Depth of Gr6i I Type of Grout _ I I Irrigation _.-Appro pth I I Eastern Surface Seal installed b p Repair Work Done ❑ of Pump H.P, State Worc Well Destruction Well Diameter Sealing Material (top 50'I az Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it puhlic sewer is ' available within 2`00(feet.) Installation will serve: Residence_ Commercial Other\�i /U e�Yr"� . ' ` .'` 'I Number of living units: r Number of be ,y A l �� - ` # Character of soil to a depth of 3 feet: kb F� p Water table depth SEPTIC TANK Type/Mfg 6 CapacityfCA4J No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal 1 SkaDk Distance to nearest: Well Foundation Property Line LEACHING LINE'. ❑ No. & Length of lines y Total length/size --FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I,1 Depth Size Number i SUMPS Ll Distance to nearest: Well° t Foundation Property Line ,..i__DISP-OSAL- PONDS= .a❑ 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractbf'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 p6rsons'subject to workman's compensa- tion laws o California." The,.t,.appficat call for all quired itions. Complete drawing onreverse side.SigD2' Title: � f , , L�•t/ �W 1'ff�/�}ate:FOR DEPARTMENT USE ONLY Ro Aped b Date '1` �^ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 t [D.Tracy 835-6385 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 DATE �, .: PERMIYNO. INFO +.EH 13-24(REV.i i N 51 1(� �j G '-' EH 1 4.28 �t3 "'�