90-1352 - Laserfiche WebLink

Home Browse Search

I I� I I� APPLICATION FOR PERMIT I I SAN JOAQUIN LOCAL HEALTH DISTRICT IE 1601 E. HAZEL T ON AVE., STOCKTON, CA P Telephone {209} 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i� (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. II• Job Address C� g City Lot Size PM Owner's Name Address - Phone _ ii • Contractor• � License NolQ/ PhoneAddress l -� TYPE OF WELL/PUMP: s NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V1•tatlustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Privat ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public Cl Other Cl Delta Depth of Grout Seal Type of Grout i I Irrigation �' .Approx. Depth I I Eastern �Su4ace Seal Installed by - Repair Work Done Type of Pump.<l&A H.P. ��L k ` State Work Done Q .r I" Well Destruction ❑ We'll Diameter Sealing Material (top 50') 11 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is �l n available within 200 feet.) Installation will serve: Residence— Commercial— Other [� 1 r: Number of living units: 1h Number of bedrooms Character of soil to a depth, iof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments 1 9 —. . -`--,—.... ,,..- -.r PKG. TREATMENT PLT.O` � '"''� -�- �•__., _Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length.of.lines Total length/size i FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS _•.Cl Oistance 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 rules and regulations ofithe San Joaquin Local Health District. iHome owner or licensei.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 II or all required inspections. Complete drawing on reverse side. Signed X o Title: AQ.� Date:,�5 Q" d O FOR DEPARTMENT USE ONLY Application Accepted by Date Area l Pit or Grout Inspection by II Date Final Inspection by Date Ufa r Additional Comments: IC ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED..� CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24(REv.11Hs) EH 14-2e s 'I I