90-95 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �I 1601 E. HAZE I ON AVE,, STOCKTON, CA Telephone (209) 466-6781 JAN 12 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRoN, - VTq( HEALTH (Complete in Triplicate) PERMIT 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. p [J ; .fob Address��rpoc7 � r? " P,.,* __— City Lot Size PM Owne('s Name /LL Address Phone Contract )9"__•AddressX&_& n_. � '.y License tyo. 6�- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER ❑ x;DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL--PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications M Public Ll Other F-] Delta Depth of Grout Seal Type of Grout - I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done �d_ Type of Pump A_,44,= 01!-�^ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I , REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial r Other (f0 Number of living units: Number of'bedrooms U1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments fe PKG. TREATMENT PLT, LI Method of Disposal V Distance to nearest: Well Foundation Property Line '. LEACHING LINE C7 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS l 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 I 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 employ any person in such manner as to become subject to workman's compensation law§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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must It for all raqu 'rred inspections. Complete drawing on reverse side. Signed XTitle: {p� Date: f -9 0 .T FO PARTMENT USE ONLY Application Accepted by Date R �� Area -� Pit or Grout Inspection by Date Final Inspection bypate -2 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 x FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +,EH 13-24(REV.+i 9 5) EH 14-2e