90-1537 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) D 3- 240--0 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor herein described. This ap lication 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.�j r.r ( -I`T' Job Address ,LC .44_01lE z=SnTSS S City Lot Size X `Yszo7 Owner's Name IM07n,rt,615 PP_oAddress 343/ W, WAR___,/ J_V #Ayb� �Phone 9.571,9-al Contractor le",`[L?._ , LOODD Address 7 Al. A.PZLA--,er Ahri�a License No. 911r7,74 Phone ! l4&f- TYPE OF WELL/PUMP: NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP'S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public D Other Fl Delta Depth of Grout Seal Type of Grout _ I Irrigation —.Approx. Depth I I`Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (Pr REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is {n Other available within 200 feet.) Installation will serve: Residence, Commercial � (' Number of living units: _L_ Number of bedrooms 4- r Character of soil to a depth of 3 feet: C-L Q Y Water table depth SEPTIC TANK ❑ Type/Mfg C} fad-4 Capacity__I�e_470 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ) Od ` Foundation 4Q Property Line LEACHING LINE No. & Length of lines 3 110 I Total length/size «d FILTER BED ❑ Distance to nearest: Well I S D Foundation �� " 9 r Property Line- 462 i 3 SEEPAGE PITS ( Depth ?S Size 4e2- " Number SUMPS ❑ Distance to nearest: Well t 50 Foundation A9 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. Signed X Title: metier-rte-� _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date � �/ 0 Area Pit or Grout Inspection b Date Zl"�d Final Inspection by awl'�� Date -a t�a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 WIN- AMOUNT Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 DUE AMOUNT REMITTED CKJV SH RECEIVED BY DATE PERMIT NO. + EH13-24(pEV. EH 1428 (a