90-663 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE® Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M�5-R 2 3 l 0 {Complete in Triplicate) S�r-�'�' J04" ,'.' '1 r'r d Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instip UBi-. iBfgirl described.jThrs;ap]flEcation 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. I i Job Address 4( 1 .14AL( City' Lot Lot Size PM 3 Owner's Name V Address ZZ/of y Phone I ContractAddress .20-0-3-i-AL-w , License fro, Phonesp 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- - _.PITSLSUMPS --- 7�1 INTENDED USE TYPE OF WELL PROBLEM AREAc.- CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom m ❑ Manteca ' -Dia.'. If Well Excavation Dia. of Well Casing ,Domestic/Private t❑ Gravel Pack + tq Tracy r +t Type of Casing g �J � . pecifications F7 Public t n Other � Ll Delta 1 Depths of Grout Seat Type of Grout _ I I Irrigation r --Approxi,Depth I Eastern ft -Surfac Seal Installed by f Repair Work Done Type of Puma t s!_ eb H.P., j4 State Work Done !YJu Well Destruction ❑I Well Diameter) N Sealing Material-(top 50') S't� I :.r Deptti Filter Material (Below 50') _ e IQ. TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION (.I 'DESTRUCTION ( I (No Septic system permitted if public sewer is W { available within 200 feet.I Installation will serve:'r Residence— Commercial Y umber of living units: Number of bedrooms p o Character of soil to a depth of 3 feet LL r" Water table depth SEPTIC TANK ❑ 'Type/Mfg�It ^f Capacity No. Compartments PKG. TREATMENT PLT.-:h- ` � } +� Method of Disposal 4l'' )Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & L•ength of lines., '+ 4 ! Total length/size FILTER ICED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number �r. SUMPS _ ❑ Distance to nearest: Well Foundation Pro f - ..... ,� Deity Line f "DISPOSAL PONDS .- - - - Y' ,= �.. 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- �� $ r 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, 1 shall not I 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." t The applicanVrropt call for all re inspe ons. Complete drawing on reverse side. Signed Title: f Date: .1�//0 '� 0 FOP DEP RTMENT USE ONLY., / Application Accepted by Date d Area f Pit or Grout Inspection by Date Final InspectioP n by DatA�' 0 Additional Comments: I ❑ Stk 466-6781 0 Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ~ INFO PATE PERMIT'NO. +.EH1241REV.iiH51 EH 14 -28