90-2147 - Laserfiche WebLink

Home Browse Search

S 4 APPLICATION FOR PERMIT J�l SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVEU 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 AUG 14 1990 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or 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 of the San Joaquin Local Health District. y� Job Address - City Lot Size PM Owner's Name Address a73� Phone Contractor�`�1� � Address OW11 X62 tri k.7`� �u- _30 License No.56b?&-2— 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other F Delta Depth of Grout Seal Type of Grout _ I I Irrigation .Approx. Depth I 1 Eastern t Surface Seal Installed,by Repair Work Done y__ of Pump,4,dl� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial T Other Number of living units: Number of bedrooms VVV Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. ✓;r Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS : 0--- I _—I hereby certify that I have prepared this application Ind 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 Di§trict. Home owner or licensed agent's signature certifies the following: "1 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 signa 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." The applicant must roquirel'ins ctions. Complete drawing on reverse side. Signed X A- . Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO REMITTED CK RECEIVED BY DATE PERMIT'N0. r EH 13-24(REV.1/M5) 90 90 r�' EH 14-2e CASH +��