91-0075 - Laserfiche WebLink

Home Browse Search

k 11 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 k (Complete in Triplicate) f4 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 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. I uG� /� t r Job Address II ! 1 lLt City �' aN Lot Size PM '` - iv£ �1Smuices Address Phone ��3�� oN�s R� $38- 7S546 Owner's Name �- Contractor �'AR�+f�� Address IS0 8UR Tu Aj Ave– _License No. �4 39)8 Phone TYPE_OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` iNTENDE6USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S ❑ Industrial W ❑ Open BOfto`m ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '� ❑,Tracy Type of Casing I Specifications Of F] Public it FIOther ❑ peltaDepth of Grout Seal rt Type of Groutt I I Irrigation i Approx.iDepth € I Eastern Surface Seal Installed by '° Repair Work Done LlType of Pump H.P. State Work.Done Well Destruction ❑ Well Diameter Sealing Material fp50:I Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if.pdblic sewer is I r available within 200 feet.)� r' Installation will serve: Residence Jz- Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet!t Water table depth SEPTIC TANK: ❑ Type/Mfg fLeCAS Capacity O— f No. Compartments PKG. TREATMENT PLT. ❑ ; •s� r .,, -Method of disposal Oistancwta nearest:" ell 'w Foundation 10 Property Line LEACHING LINE 21"'No. & Length of lines 'T V c Total length/size FILTER BED #� ' ❑ Distance to nearest: Well Foundation dati = + i II Property Line SEEPAGE PITS I 1 Depth f Size SUMPS ii Ll Distance to nearest: " WellFoundatieTlz f+ 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 1 rules and regulations of the San Joaquin Local Health Diktrict. t7 i f 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 shalt not employ any peron in such manner as to hecome subject to workman's compensation laws of California." Contractor's hiring or suh-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of Catifomia." The applicant must call for all re uired ins ions. Complete-drawing,on_teverso,side. ` SignedfX ��' T Title: Date: i OR DEPARTMENT USE ONLY t -- 'Application Accepted by �A0 L �� = iDate ea Pit or Grout Inspection by Date Final Inspection b Cts Date/ I 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 r AMOUNT DUE**f-—AMOUNT"FiEfAITTED `FI '_,B `r" ." A � O. INFQ CASH AECEIVEp BY DATE pE:RMIT�N t.EH 13-24(REV.tifs5) `! 4, EH EH 14-2 114; -'. 0 �—� r