90-914 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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. r �} A ff Joh Address i �a` l b /Z�� r • - City ��r Lot Size 4,c� PM Owner's Name �1 Address I r �T `�+ f Phone A � Contractor€ll P+If JJZjefJ Address 59 k C �tJ Rd License No. Phone_A$': TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J9 SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 10 0 DISPOSAL FLD.1.50 PROP. LINE 3-_ FOUNDATION IS"O AGRICULTURE WELL OTHER WELL_-_1S-0— PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fit ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing rcer Z_ Specifications 17-, M Public f 1 Other 1-1 Delta Depth of Grout Seal Type 9f Grout 5 R�Cfi-b G� 1 � f € C.. I I Irrigation --..Approx. Depth �II Eastern Surface Seal Installed by W© E l 0 9.. Repair Work Done ❑ Type of Pump 'Lf L7 H.P. .. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I] 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 Di§trict. 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."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 call for II requir d inspections. Complete drawing on reverse side. p Signed X Title: Date: FOR DEPARTMENT USE ONLY PIZ Applicatio Accepted by Date )Area Pit of rou Inspection by Date �� Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 535-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE P RMIT'NO. INFO CASH _ F EH 14-241REV.5/H51 �'7 t(, EH 14-28 [[[.,,...JJfJJJ tt 11 /