90-517 - Laserfiche WebLink

Home Browse Search

i I G APPLICATION FOR PERMIT '�" "� • -` SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE.T ON AVE., STOCKTON, CA { Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install 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 ofd a San Joaquin Local Health District. �D� hn a Li�+q an!✓ City Lot Size PM .fob Address I` RQ Address ^ �� K Phone Owner's Name � 4 Still lC9 IF , Contractor Address �tt�G�^ctt4 License No.—Phone B TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION [Ivgrpe p,..6Cd PUMP INSTALLATION ❑ SYSTEM REPAIR L3OTHER .04ew+` .. � PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _AGRICULTURE WELL 07HE WELLD PITS/Slumps FOUNDATION ,w ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o be.� + l Industrial ❑Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack [5g Tracy Type of Casin r a , '4 "410'Specifications FPublic s Other 171Delta Depth of Grout Seal 01�'1 e of Gr I I irrigation "'A pr�ox�.�Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump —��— H.P. State Work Done Well Destruction ❑ Well Diameter -. —�- Sealing Material (top 501 Depth f ' Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTION I l ;Noave septic system permitted if public sewer is Q available within 200 feet.] Instaliation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ICapacity�– No. Compartments ►� SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ I Method of Dis osal Distance to nearest: Well N Foundation !NI 4a Property Line ]— I LEACHING LINE ❑ No. & Length of tines -� Total length/size FILTER BED ❑ Distance to nearest: Well. r Foundation_.,_ _ Property Line N/r v I SEEPAGE PITS I I Depth inSize C _ Number SUMPS Ll Distance to nearest: Well Foundation .— Property Line DISPOSAL PONDS Cl . I hereby certify that I have rrepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the an 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 subiect to workman's compensa- tion laws of California." The applicants must tccall lffor all required inspections. Complete drawing on reverse side. Signed X Title: ,fEi 6, r Date: FOR DEPARTMENT USE ONLY (� Application Accepted by Date / Area �� 5 Pit or rout spection by Date 3 Final Inspection by Date �f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copiers to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK R RECEIVED BY DATE PERMIT No. INFO +-EH 13-24(REV.I/n 5) EH 14-28