90-1903 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQVIN LOCAL HEALTH DISTRICT RECEIVEU 1601 E. HAZEL T ON AVE., STOCKTON, CA { Telephone (209) 466-6781 0 U L 2 3 1990 4 PERMIT EXPIRES TYEAR FROM DATE ISSUEDENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby 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, 1 Job Address ++ City Lot Size PM Owner's Name � to N Address Phone Contractor AddresA& d. License No. pL Phone TYPE OF WELL/PUMP: EW WELL XL WELL REPLACEMENT4 DESTRUCTION ❑ PUMP-INSTALLATION ❑ - SYSTEM REPAIR - OTI JER-�❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES �fii0t �' DISPOSAL FLD.. PROP. LINE f FOUNDATION-. . AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARA CONSTRUCTION SPECIFICATION jj Industrial i Open Bottom ❑ Manteca «-y---Dia: of-Well Excavation Dia. of Well Casing Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing S -1'11Specifications FI Public ❑ Other , f� Delta Oepth-of Seal - L�� Type of Grout I I Irrigation I --Approx. Dep 1 Eastern Surface Seal Installed by Repair Work Done %Type of Pump H.P. State Work Dane_ Well Destruction {Well Diameter ; Sealing M al (top 501 Depth Filler Material (Selo_w 501 TYPE OF SEPTIC WORK:. NEW INSTALLATION 1.1 REPAIRIADDITION i I DESTRUCTION i l (No septic system permitted if public sewer is I available within 200 feet./ Installation will serve: Residence 16ommercial—_ Other ` Number of living units:I Number of bedrooms 1 Character of soil to a depth of 3 feet:r. - Water table depth SEPTIC TANK 0-Type/Mfg ,_ Capacity- No. Compartments PKG. TREATMENT PLT. ❑ ` a Method of Disposal \ Distance to newest, Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines � Total length/size � '-�-- i FILTER BED ❑ Distance to nearest: Well Foundation-L-�---�----Property Line a �1 SEEPAGE PITS I I Depth `� Size _ Number SUMPS _.i L] Distance to nearest: Weil Foundation Property Line 4� -DISPOSAL PONDS -`:., ❑ r 4 I hereby certify-ihat 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. Home owner or-licensed agerit's signature certifies the following: "I certify that in the perfo1rmance of the work for which this permit is issued, I shall not employ any person such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio m "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.1 r a." The applican st call for all requir nspection . Comple a drawing on rawer a ide. Signed X f A Title: ate: OR QEPARTNIE USE ONLY Application Accepted by Date d Area / Pit or Grout Inspection by ,e� //�/��,, Date Final Inspection by Date Additional Comments: 7�� 1 •._t'Xi(—, _ _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Vacy 5-6385 Applicant - Return all copies to: Environmental H Ith Permit/Services 1601 E. HazeIt Ave„ P.O. Box 2009, Stk. CA 9 Ol FES ti�� .�� % wr. AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. /r a.EH13-24(REV.1/k 5) y. EH 14-26 1 OC2O