90-436 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s. (Complete in Triplicate) i District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local Health made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 far welllpump and the Rules and Regulations of the San Joaquin Local Health District. Q�/—"�'1 ��l City Lot Size PM Job Address 'NOC`en� 1 �7 C A1tX_ ,47 0 9 3 S "F�3 Owner's Name 1 Address� � � ]'hone Contractor Address 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 ❑ Industrial ❑ Domestic/Private ['1 Public i 1 irrigation Repair Work Done L1 Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " ❑ Gravel Pack ❑Tracy Type of Casing 17 Other f (7 Delta Depth of Grout Seal _.-Approx. Depth l I Eastern Surface Seal Installed by H.P. — State Work Done . Type of Pump Well Diameter: Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REP4 installation will serve: Residence , Commercial Number of living units: Number of bedrooms — Character of soil to a depth of 3 feet: ' SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: Well LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Wel RIADDITION i I UtJ Dia. of Well Casing Specifications Type of Grout o septic system permitted if public sewer is available within 200 feet.] Water table depth _ Capacity No. Compartments Method of Disposal dation Property Line SEEPAGE PITS I I Depth I Size SUMPS Ll Distance to nearest: Well Foundation Total length/ size_ Property Line umber Property Line 0 DISPOSAL PONDS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health DiWict.1 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, shall no 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: 111 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." I The applicant111n"St call for all r uired inspections. Complete drawing on reverse side. L ` -D�� a Date: Signed X / , r Title: I F DEPARTMENT USE ONLY Datey Area Application Accepted by bap WSL- Pit or Grout Inspection by Date Final Inspection by 4-1 ow T' .4SO4477o •.% Date 2 l" #_1 KCujC. W r -c //a°—./"i2ocK TD Additional Comments: E Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r.EH M24 IREV. 5/K 57 EH 14-2e