90-435 - Laserfiche WebLink

Home Browse Search

y APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 rt 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 Joagiiiil i' ;.`: Local Health District. c� Job Address City `�� t Size PM Owner's Name AMRM1�Address Phone r Contractor Address License No. Phone n TYPE OF WELL/PUMFV NEW WELL ❑ WEL REPLACEZP DESTRUCTION ❑ PUMP INSTALLATION ❑ S STEM ROTHER ❑DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W LLOTHER WELL, PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private I.1 Public { I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack ❑ Other I _..Approx. • Depth Type of Pump Well Diameter Depth PROBLEM AREA CONST CTION SPECIFICATIONS ❑ Manteca /Dth II Excavat7by ❑ Tracy Ca 'ng C1 Delta f Gro t Seal I }Eastern Seal ! calleH•P• ork Done A Material (top 50') 'Material (Below 50') Dia. of Well Casing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is AMOUNT REMITTED CASH available within 200 feet.) PERMIT NO. Installation will serve: Residence �_ Commercial _ Other 0 Number of living units: i Number of bedrooms �`� -- Character of soil to -a depth of 3 feet: i Water table depth --I. Z-0 w _ SEPTIC TANK ❑ Type/Mfg Capacity 162 No. Compartments 2– lrq PKG. TREATMENT PLT. ❑` Distance to + ,t Method of Dispgsal ' 0 k S nearest: Well _Sp Foundation Property Line.T LEACHING LINE FILTER BED V No. & Length of lines �2_ T07al length/size_ ❑ Distance to nearest: Well ib0 Foundation V<_1_7_ Property Line SEEPAGE PITS I 1 Depth SUMPS K Distance to nearest DISPOSAL PONDS Cl Size _- 67 t A I V.._ Number Well t D O Foundation I )-C). ( Property Line i_�o— 5 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: "1 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." Contractors 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 appli1mustcallfor I r ired inspecti S. Co p to drawing on reverse side. Signed X Title: Date: I ��RTME111T USF ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date rtr Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 1 +- EH13-24 {REV. t / H 5 EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f �`� -7h cyz!� tit 1 90 Qo�y3s