90-2636 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 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. Job Address t-�+ �� City Lot Size , Owner's Name gd Address s; ' Phone " F r � Address b� r ) License No. +` 'ZZ1(O Phan, 0-5 Contracio TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e _ ❑ Industrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑;Trac`y ._I,--�/Type•of Casing Specifications I I Public f} Other r ❑ Delta Depth of GroatSealType of Grout I E Irrigation -_.Approx—be-pth 'l I Eastern -Siurface'Seal Installed'-by' i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 �� I - Depth l Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is v available within 200 feet.) Installation will serve: Re"dente"' Commercial_ Other r Number of living units: >Y"-- Number of rooms Character of soil to a depth�of 3 feet. r Water table depth Q SEPTIC TANK %me, Mfg i Capacity �t?Q 1� No. Compartments " PKG. TREATMENT PLT. ❑ tp f r Method of Dipposal ti "Distance to nearest: Well ._ Foundation��_ Property Line LEACHING LINE No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: WellI Foundation � - �- - Property Line SEEPAGE PITS Depth S Size tt�f!�� _ Number `—� I SUMPS Ll Distance to nearest: Welhty Foundation -Qf Property Line �.. I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and t'ha't the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DrItrict.7 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 ws of California.". `,i''°•- ""`^ '-- ..� The applicant• . tali-for ai equ' d inspections. Complete drawing on reverse Signed X1 Title: t Date: .c FOR DEPARTMENT,, USE ONLY Application Accepted by Date N I �t%� Area, !� or Grout Inspection by '' Date Final Inspection by�?,_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE t AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13-241REV.iiA 5) f, EH 14-26 LLL..rrr117LLL S ' r