90-960 - Laserfiche WebLink

Home Browse Search

Ga APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1E01 E.*HAZ•El_TON 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 1` City Lot Size '► PM T._ Owner's Nameddress `Phone ,- p Contractor l/ Aress ��Q License No. U� Phone z TYPE OF WELT./PUMP: NEW WELL WELL REPLACEM;NT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM! REPAIR 0 OTHER ❑ / DISTANCE TO NEAREST: SEPTIC',TANK— EWER LINES- i–�-�A–�j_- DISPOSAL FLD.� PR , OP. LINE FOUNDATION �� ` AGRICULTURE WELL./ '�THER WELL .�'� PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CON STRUCTION`SPECIFICATIONS C/ Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavaiion 1 7 Dia. of Well Casing omestic/Private �Gravel.P.ack 0 Tracy� � Type of Casing Specifications_IV q �–�- Fl Public r n Other . . Cl Delta Depth of Grout Seal Type of Grout i I Irrigation – C2 pprox. Depth I I Eastern Surface Seat Installed by U- Repair Work Done ❑ Type of Pump H.P. �-- State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J Commercial— Other Number of living units: ' Number of bedrooms Q i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ hype/Mfg ti _Capacity _ No. Compartments_ PKG. TREATMENT PLT. ❑ } ,, Method of Disposal i t 'Distance to nearest: We11 Fo ndatio - = �\Property Line LEACHING LINO _ '❑ kNo. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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: "( 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,(shall employ persons subject to workman's compensa- tion laws of California." The applica mus a a req ' ns. Complete drawing on a Xrse side. Signed X Title: Date: 4Z?_��OL FOR DEPARTMENT USE ONLY t1 Application Accepted by 6k, .w r Date 3) Area r 6 Pit or,Grout I spection by�� Date S s`�� Final In ectign by �t� _ Date Y C_;i Additional Comments; l_�P.tla (L)2— 9� 8-r' low ,)y -i 1(22 ❑ Stk 466-6781 . ❑ Lodi 3 A.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO dt, CASH ♦.EH 13-241REV.1in51 �� p - `EH 14-25 (,/ 1