90-2717 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ; j Telephone (209) 466-6781 >� (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in Triplicate) t Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or ins talk 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. >) A� City G Lot Size PM Job Address _._ Address Phone Owner's Name 9 License No.;�Phone_ 1 Contractor__ L6 t l�G�� r� Address d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER ❑ _ _ _ -.-..-..,�....--•-�"'*^..',-"__. rte+ '� DISTANCE TO NEAREST: SEPTIC TANK .W SEWER L{NI S QESP46AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL _, PROBLEM AREA CONSTRUCTION SPECIFIOATIONS•, I ❑ Industrial ❑ Open Bottom_ -i]-Manteca--•---►Dia.-of,Well Excavation— A - {' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Type of Grout M Public Cl Other 71Delta Depth of Grout Seal i ! I I Irrigation _Approx, Depth.. t L Eastern Surface Seal Installed by � ! F~ 1. H.P. State Work Done _ i Repair Work Done ❑ Type of Pump L + Well Destruction LiWell Diameter Sealing Material (top 50') (Depth Filler Material (Belo+nl501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION,{ I'(No septic system permitted if_puhfic_sewe{is i • ,, x fi 1� available within 204 feet.) # Installation will serve: Residence Commercial` Other II Number of living units: Number of bedrooms�. —Clhuactef-of-soii to a depth of 3,feet.: ry �-,HT1 � � { - Water table depth SEPTIC TANK ❑ Type/Mfg ( Capacity �AlC mpartments �_.-___ ' f i ! •' .� Method of Disposal PKG. TREATMENT PLT. ❑ i Distance to nearest: Well Foundation Property Line + ! Total length/size 1 LEACHING LINE No. & Length of lines �_,�!�- 4' FILTER BED ❑ Distance to nearest: I Well — Foundation L Property Line .a !! 'SEEP 1 Size + M 1 Number ! 4 t: AGE PITS I ! .r Depth. r y i; + , SUMPS ❑ Distance to,nearest: Well' Foundation Property Line ;. DISPOSAL PONDS \❑,•�`,' ,e' III + I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,;sial a laws, and iules and regulations of the San Joaquin Local Health 4Di§trict. tom` t s Home owner or licensed agent's signature certifies theifollowing: "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 fo workman's conipensation laws�oi California."Cod tractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit isrissued, I shall employ persons sub jectiio workman's compensa- tion laws of California." " ` '._,. The applicant must call for II req 'red inspections. Complete drawing on reverse side. 6 I ' ined X Title:(( Date: g I. 4 y Y 4 1 tr it S' DEPARTMENT USE ONLY . Application Acceptad:by Date Area Q ryy Q �� ! ' r l �'! I 0 Pit or Grout Inspection by ate_ r - _.,Final Inspection by Date i Additional Comments: � _ g CJ„Stk 466;6781_17 Lodi 369 3fi2t ❑ Manteca_ 823 71, 4 ate' [Itraa6y 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601^E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 i LC;AS ry IFEENFO AMOUNT DUE i AMOUNT REMITTED _,. _ 'RECEIVEDII3! DATE PERMIT NO. '+SEH 13-241REV.tia51 EH 14-29