90-597 - Laserfiche WebLink

Home Browse Search

aii - "'"S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA ft D Telephone (209) 466-6781 MAR 12 00 PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDSAN 1� (Complete in Triplicate) J '� ICOUNTY LIOWC Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install WWOMWAP tion 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"Jbaquin Local Health District. Job Address BL-va, 199 15"Pe PA b o-r City "_r14 -05 Lot Size NA PM NA Owner's Name U.5. DEPT OVIM- AktAV Address O'rH ROA0 L-ATIA 2 Phone ZC0q487`Z Contractor_:SPF-GT12NVA EXI LDIZA7IQA�,ddress NZ5IE IAY9_TLC AVE -OcKlEA)l icense No. Phone lbs`i7� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER)e SbIL QORILt65 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom LlManteca Dia. of Well Excavation (a_IS .{ Dia. of Well Casing AJA ❑ Domestic/Private ❑ Grave{(�y�pack ❑ Tracy Type of Casing Nle Specifications f-1 Public ❑ I rt ' [_] Delta Depth of Grout Seal 'TQrAL DEITHType of Grout CES BE&;T i I I Irrigation __..Approx. Depth l I Eastern Surface Seal Installed by ! RILLEi2 _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION ["I REPAIR/ADDITION [ I DESTRUCTION I 1 INo 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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, 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." 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 required inspections. Complete drawing on reverse side. 5,eo- '5-Xmp1,A1,j PlQVI � Signed X� �{, _P- �J.:�r�. Title: . +ppr,4 9 i>z er eDate: 3-$ c-f 0 The MA P-t4 Grc«p1 ENi-s•`i 6,11. irr QE 41- EIVT USE ONLY�xPlOn��iO�l Application Accepted by Date e Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH +.£A 13-24(REV.i/nal 73 ,5O 0 ^LZs3 EH 14-26