90-140 - Laserfiche WebLink

Home Browse Search

n APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 i Local Health District. Job Address � � X0_6 il�fLY��( '� City Qr_ CJQVW Lot Size A� �Pd PM � \ F�Yt '\ Owner's Name Address _Ut 1�> Phone I �f � Contractor �+ 1. Address d 330 Aft 00VRRJ2 S I r License No._=C01 fT_ K Phone`77"9A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y Cyt,,4.� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ED Other Cl Delta Depth of Grout Seal Type of Grout I I irrigation ---Approx. Depth { 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 `q Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is O available within 200 feet.) 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 �aii No. Compartments PKG. TREATMENT PLT. ❑ 1 r,III!I I Method of Disposal Distance to nearest: Well ma l,Fooc�� sfi lflft#h0 � Property Line G �Y LEACHING LINE ❑ No. & Length of I"lyrry� e eu Ul 11 to Total��yength/size li FILTER BED ❑ Distance to nearest: iyUell. v L �t�r� fii i ,,�t� '" Property Line , SEEPAGE PITS s i I Depth Size Number SUMPS Ll Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ 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. 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 n s 1 s employ any person i such manner as to become subject to workman' compensation laws of California."Contractor's hiring or sub-contracting signature t 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." Theapplicant mus all f r all required ins tions. Complete drawing on rever side. Signed X Title: —6 Date: �L? FO DEPARTMENT USE ONLY Application Accepted by Date a `Z 7 r- Area Z Pit or Grout Inspection by Date Final Inspection by Date Ile— Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE RERMIT'NO. INFO ♦.EH 1 -24(REV.�i n SY 4O �06 EH 14-2t3