90-377 - Laserfiche WebLink

Home Browse Search

I ` APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �t l 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 -3-3 , �Y City Lot Size PM Owner's Name Address Phone � 3 Contractor Address der— License No.3f(92?le Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r°`AGRIC0L'TURF_WEL'L`"`""""'s OTHER_WELL�" s _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE 5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. �ofGrout cavation Dia. ofWell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ypeng Specifications -rJ f'1 Public ❑ Other to DeptSeal Type of Grout ._ I i Irrigation —__Approx. i I Eastern Surface Seal Installed by Repair Work pone L-1Typeof P p H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth- t Filler Material [Below 50') r _ I< TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION l ] DESTRUCTION [No septic system permitted it public sewer is s available within 200 feet., ry � ce a J ` — Installation will seReside Commercial_ Other n Number of living units: 9 Number of bedrooms �`.} Character of soil to a depth of 3 feet: I + Water table depth SEPTIC TANK ❑ Type/Mfg Capacity'!!+ No. Compartments rV PKG. TREATMENT PLT. ❑ ; Method of Disposal Distance to nearest: Well Foundation Property Line I } v LEACHING LINE ❑ No- & Length of lines - =X Total length/size t FILTER BED ❑ Distance tri nearest: Well Foundation °�2 Property Line SEEPAGE PITS i I Depth Size .-----Number- ' � SUMPS Ll Distance to nearest: f 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, and rules and regulations of the San Joaquin Local Health Di$trict. 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 mu call for all required ins ctions. Complete drawing on rev rse side. Signed X .Title: AC; --bate: rt OR;DEPARTMENT USE ONLY r Applic' ion Accepted by datei= aAre Pit or Grout Inspection by Date~ Final Inspection by Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Manteca 623-7104 L1 Tracy 835-6385 Applicant - Return all copies to: Environr6irital Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r> i IN MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. t-EH t3,241REV,r/K51 i EH 1428 � � �