90-457 - Laserfiche WebLink

Home Browse Search

f 4 S APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA t 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 fora 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 # Job Address rk ~Ot>'� µ �� City mAAJr°g(A Lot Size PM Owner's Name _'Rtw BA go Address Phone Contractor tIM 1L'�R.�•11.e Address AGO &�� AM 2y3�11� Bz3 'LS License No. 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE._ -TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public n Other LI^Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Depth { I Eastern' Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction t ❑ Well Diameter Sealing Material flop 501 f i {� I Depth Filler Material-Welow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I E DESTRUCTION I 1 Mo septic system permitted if public sewer is 1` r f available within 200 feet.) i Installation will serve: Resl e"mance—__16Comme'diW"— ^'-Othe Number of living units: * Number of bedrooms t, } Character f soilta a depth of 3 feet:} 11 Water table depth SEPTIC TANK s ❑ Type/Mfg: 4 Capacity 0 No. Compartments q d PKG. TREATMENT PLT. ❑ i ... r Method of Disposal f ) 1 Distance to nearest: we if/ff Foundation I Property Line f { rl AHC +° true d �' I� la+tl t�} CG., € LEACHING LINE ❑ No. & Length of lines Total length/size = FILTER BED ❑ Distance to nearest: ' Well Foundation ` Property Line s SEEPAGE PITS f 1 . Depth Size + V Number SUMPS # ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application ani 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 followin r "1 certify that in the-performance of the work for which this permit is issued, I shall not employ any persoh in such manner as to become subject'6workman's compensation law-'sof-California." Contractors hiring or sub-contracting signatuie certifies the following: "I certify that in the performance of the work for which this permit is issuad;,lshall employ persons subject to workman's compensa- tion taws of California." i r The applicant m= all for all required in ctions. Complete drawing on reverse side. _ � y r� _._ - Signed fes` . ` Title/ l Date: — — 7— 1 FO EPAR ' ENT USE ONLY Application Accepted by Date 4� Area j Pit or Grout Inspection by Date Final Inspect on by Date 3 .0 Additional Comments: It i ❑ Stk 466-6781f ❑/Lodi 369-3621 f ❑ Manteca 823-7104 ❑ Tracy 835-6385 i t Applicant:,F,ieturnall.copies.to.-Environmental-Health_Permit/•Services 1601-E—Hazeiton-Ave.,P-O—Box 2009,Stk..,-CA-95201 S FEE AMOUNT DUE ', AMOUNT REMITTED �� INFO RECEIVED BY DATE PERMIT'NO. t EH13-21(REV.rin51 ,o Ito c - ��1 O 9�"' S EH 11-29