90-2117 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT r ��✓ "ef� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is her 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 welppump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address City v © Lot Size PM f f' SPhone Owner's Name � lyse � r` t Address d2 0 e) License No. J 76�� hone Contractor Address TYPE OF WELL/PUMP: NEW WELL EIWELL REPLACEMENT f7i DESTRUCTION Ll I PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER ❑ ' "SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L1Gravel Pack LI Tracy Type of Casing Specifications F] Pu61ie MOther "k ❑ Delta Depth of Grout Seal Type of Grout---- I rout I I Irrigation _.Aper x. Depth l I Eastern Surface Seal Installed by RepairWork-Done ,❑ Type of Pump H.P. State Work Done T j Well Destruction ( Well Diameter Sealing Material (top 501 t Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: N INSTALLATION REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) i Inst Ilation will serve: Residence A Commercial Other Number of li4ing units: __ ,L-, Number of edroo s ==character-of-soil�to--'_depth of 3 feet: n Water table depth ct;'t C r s= Ca acity�� No. Compartments � SEPTIC TANK (y; Type/,Mfg p PKG. TREATMENT PLT. 1-1 "` Method of Disposal - Distance to nearest: Well Foundation Property Line01 LEACHING UNE ❑ No. & Length of lines Total length/size a FILTER BED ❑ Distance to nearest: Well_L Foundation/D Property Line .. .._ SEEPAGE PITS 11 Depth °..� _Size Number SUMPS Cl Distance to nearest: Well Foundation Pro- �, perty Line DISPOSAL PONDS ❑ I V'y 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 Diltrict. 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 nowt`, + employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 m st call for requ'ed ins ctia s. Complete drawing on reverse si e. Signed X� - Title: Data: �5 - -- FOR ART N SE ONLY Application Accepted by Date r/G ti � Area it r Grout Inspection by at Final Inspection by Datee.,-5-7/ C?V Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ !Manteca M-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 MAMA�OUIUT`DUE*:--—AMOONT REMITTEDYCASH'""RECEIV60-BY ,,.+ DATE - '�' PERIN'IT NO INFO , �a +,EH13-24iREV.t/H51 .S EH 1426 .