90-3012 - Laserfiche WebLink

Home Browse Search

Er i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT d, I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE I UED Nov `' (Complete in Triplicate) /JIRp1VJW�.1 8/I 19'90 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insla 1tiu ' e�efri�d � This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruldsv dMnea � e San Joaquin Local Health District. CrY � Loes- Job Address � Z , C7� City Lot Size PM Owner's Name Address O Phone �Q I Contractor E.1 ddress License No. Phone_ t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ w --- - �� ---PUMP INSTALLATION-C1 -- -�--- SYSTEM-REPAIR -_ --OTHER- 17---- --- ----�- DISTANCE TO NEAREST: _SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION w. AGRICULTURE WELL'_ 'OT L-" 4 PITS/SUMPS INTENDED USE. TYPE OF WELL PROBLEM AREA C6NSTR6CTlO1WSPECIFICATIONS y -E1industrial.....-.v �- ❑ Open_Bottom_ C1Manteca_—Dia.-of-Well Excavation--- ,,,D..ia._o_f_Well Casing._ C✓� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i i r`l Public n Other 171 Delta Depth of Grout Seai Type of Grout f ISI Irrigation —..Approxi Depth l 1 Eastern Surface Seal Installed by - 1 f1 Repair Work Done ❑ Type of Pump �_ H.P. State Work Done Wel1'Destruction ❑ Well Diameter /I f/ Sealing Material (top 50'1 A Depth I Filler Material lBelow 50') 4 t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I l INo septic system permitted if public sewer is s l available within 200 feet.) ff Installation will serve: Residence J Commercial— Other r Number of living units: Number of bedrooms I I r Character of soil to a depth of 3 feet! Water table depth = - -- i t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l PKG: TREATMENT',PLT. ❑ Method of Disposal 6 Distance to nearest: Well Foundation Property Line 1' 1 t LEACHING LINE D No. & Length of lines Total length/size FILTER BED f ❑ Distance Ito nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS Ll ,Distance to nearest: Well Foundation ---�-----=Property Line DISPOSAL PONDS ❑ "I ��Y I hereby certify that I have prepared this application and that the work will be done in accordance wiyh San Joaquin county ordinances, state laws, and rules and regulatioris of the San Joaquin Local Health Diltrict. '" f 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, V shall not employ any person in such manner as to become subject to workman's compensation 1a%v s.of California." Contractors hiring or sub contracting signature certifies the fol ' ng: "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 C lifo nia. ' The appli nt t call for all r q ired inspe ns. Complete drawing on raver a side. Signed X Title: Date: F R DEPARTMENT USE ONLY _ 4 Application Accepted by DatArea Pit or Grout Inspection by Date Final Inspection by` 2 2 Date Z Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 535-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT ND. } INFO AMOUNT D UE CASH ` 3 4-EM 13-24 IpEV.1=H51 EH 14-28