90-3118 - Laserfiche WebLink

Home Browse Search

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. ace- PM Job AddressI -- City Lot Size �- r Owner's Name {1—"7'� Address Phone r y ��Z 1j /`� T t Contractor/ dress f ✓o License No. �3 3 Phone Y 22 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM AIR ❑ OTHER C3 - DISTANCE TO NEAREST:_ SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RICULTUR ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing CP ❑ Domestic/Private ❑ Gravel Pack L Tracy Type of Casing Specifications f'] Public ❑ Other n Del Depth of Grout Seal Type of Grout—.--- I rout __I I Irrigation _Approx. Depth I I stern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Seal g Material (top 501 ' Depth Filler aterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i. REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is 1 available within 200 feet.l Installation will serve: Residence" Commercialther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,e SEPTIC TANK ❑ Type/Mfg io "6 y Capacity2j)� No. Compartments �p PKG. TREATMENT PLT. ❑ � _ Method 4 Disposal Distance to nearest: Well ��[1t Foundation Property Line {} LEACHING LINE 0 No. & Length of lines I WTotlngth/sizeFILTER BED ❑ Distance to nearest: Well oundation Property Line r SEEPAGE PITS i I Depth 71 Size Number SUMPS ❑ Distance to nearest: We! Foundation M 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 DRtrict. 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."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 applican ust call for quired in pectiorls. Complete drawing on reverse side. �J Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Data Area N or Grout Inspection by Date final Inspection by Date Additional Comments: _ ❑ Stk 466-6761 Cl Lodi 369-3621 •tD Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. +.EH1 -24{REV.iiHs) T EH 144-2e 1LL--