90-2721 - Laserfiche WebLink

Home Browse Search

ti APPLICATION FOR PERMIT » � SAN JOAQUIN LOCAL HEALTH DISTRICT 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 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. / / Job Address - yQtit 46Ae_, r City _ Lot Size PM 1 Owner's Name Address j Phone��^" Contractor Address AV2 md License No%57��Phone ' Z- i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I�_ SEWER LINES � DISPOSAL FLD. PROP. LINE �"'` • "�`' -�-- -FOUNDATION AGRICULTURE AGRICULTURE WELL OTHER WELL5_*� ._._._. PITS/SUMPS lJ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' T-- E) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion f +�3 Dia. of Well Casing �omestic/Private b4_Gravel Pack ❑ Tracy, Type of Casing_- r}� Specifications � lJ I 1 Public (1 Other i l Delta i Depth of Grout Seal �,,,,s Type of Grout k >'I"I irrigation --Approx. Depth I i Eastern Surface Seal Installed bq Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') . J Depth Filler Material {Below 50') /. TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is " available within 200 feed Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK `❑ Type/Mfg} Capacity No. Compartments r PKG. TREATMENT PLT. ❑ i S Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines', ' ' ' Tota! length/size # (- FILTER BED }❑ Distance to nearest: Well Foundation A Property Line r SEEPAGE PITS I I Depth Size - _ Nurrrrber- 'J SUMPS Ll Distance to nearest. Well Foundation ~' Property Line ' DISPOSAL PONDS ❑ x: fy '�"""�`"rulesea do ertlulat onsl ofathe S n J aprepared t urn Lochis applalaHealth tion and d strat the ict' `"or�k�will Abe done accordance with San Joaquin county ordinances, state laws, and 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 subject to workman's compensa- tion laws of California." c The applicant must call for all required inspections. Complete drawing on reverse side'• Signed X-01 4 r Title: Date::!?__ I '" 9D ---FO -DEPARTMENT USE-ONLY-- Application ONLY,...-.^.-"- Application Accepted by t- Date Area t ] Pit or ra Inspection by Date". �.r�Gfinal Inspection by Dat�� Additional Comment0k ivyof ❑ Stk lic 466-6781 ❑ Lodi 369-3921 ❑ Manteca 82 -7104 Tracy 835 6385 (f~G�,� � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 01 FEE AMOUNT DUE MOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N INFO CASH r i +.EH 13-24{REV.t EH 14-29 ! V G l y 40 - �15 G�`2?� 1 ■