90-135 - Laserfiche WebLink

Home Browse Search

APPLICATION TOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Jaquin-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. } t l i P Job Address (Z� t`�7� F l r' �� —,_ City4!�CkDJQQ Lot Size Zl/)— PM I '4 , 2 Owner's Name � Address f " P,[ �� phone Contractor fl't 1 � p i ddress License No.z �. 51Ph.ne TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEMREPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� ry,�, �� _ SEWER LINES DISPOSAL FLD.P�,PROP. LINE r $ FOUNDATION JSP � AGRICULTURE WELL�OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f_ n ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing " -Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public ❑ Oth ❑ pelta Depth of Grout Sea! �� Type of Grout E I Irrigation �_..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done VL Type of Pump .- - m H-p. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is / p Installation will serve: Residence_ Commercial� _Other available within 200 feet. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED LJ Distance to nearest: Well Foundation Property Line C PL SEEPAGE PITS I I Depth Size Number _ SUMPS Ll Distance to nearest: Wellr Foundation DISPOSAL PONDS Property Line 11 � 4 F I hereby certify that I have prepared this application and that the work will be done in accordance with San d state laws, an Joaquin county ordinances, rules and regulations of the San Joaquin Local Health District. I� Home owner or licensed agent's signature certifies-the-following:-"I certify-that-in jhe 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 applican st call for all required inspections. Complete draw 1 , p g on reverse side. Signed Xitle: ^ /� Date. FOR DEPART ENT USE ONLY Applicatio ccepted by ' r Date a z i ea Pit or Gro Inspection by by Inspection Date Final Iion � l Data Additional Comments: ,� , r ❑ 5tk 466-6781 di 369-3621 CI Manteca 823-7104 f ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services' 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 i I '� I FEE- ---A VjNT-I)L1E AMOUNT REMITTED CK INFO ,y�� —RECEIVED�Y DAT" E—pERM17'NO. a,EH 13-28IREV.tirs5l } 'D VV ' 0S r— �3 EH 11-28 J