90-257 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781. PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) t to d/or install the work herein describe . This cation Applicaion compliance writh SanoJoaqu the n County Ordinan Joaquin lncle Nth District for a o.549 for sewage r No 1862 forcwell//pump and the Rules and Regulations of he San made is Local Health District. I� �44 � Cit A) Lot Size PM Job Address , I / Owner's Name S U��Address �v�� /V r S 7� -S Phone k, Contractor �e F Address. �Z3 �°' �v tf+° ` License No. Phone -5/9/1 TYPE OF WELL/PUMP! NEW WELL El REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION F1SYSTEM REPAIR LlOTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El INTENDED 11 Open Bottom El PROBLEM Dia. of Well Excavation Dia. of Well Casing El Type of Casing Specifications ❑ Domestic/Private L1 Gravel Pack I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth t 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 n Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIRIADDITION l I DESTRUCTION (No septic system Permitted if public sewer is 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 Capacit No. Compartments SEPTIC TANK ❑ Type/Mfg y Method of Disposal PKG. TREATMENT PLT. ❑ I Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED ❑ Distance to_nearest: Well Foundation Property Line Q SEEPAGE PITS I l Depth Size Number i SUMPS L1 Distance to nearest: Well Foundation Property Line t 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 y rules and regulations of the San Joaquin Local Health Dil;trict. —1 l 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." The applicant must cell for ail required inspections. Complete drawing on reverse side. r C� , Signed X Title: Date: FO DEPARTMENT USE ONLY Application Accepted by Date a1` — Area iii Pit or Grout Inspection by Date Fial Inspection by Date 1/o3lq G--/ ke was I Additional Comments. r ❑ 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 REMITTED AS RECEIVED BY DATE PERMIT'NO. INFO ` � +.EH 13-24(REV.$/A 5f CTL v `�rrS '!A'•J `+n� ��0 EH 14-26