90-2906 - Laserfiche WebLink

Home Browse Search

F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �V 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 1 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 Di ict. r l� • �,I f Lt e�I C�d-t�nJ �.nJ�_ ' Oq-7- Lh o Job Address f City Lot Size PM Owner's NameAddress So 0 Phone W Contractor fJ� L Address A License No.ZIi 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r� v i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 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 xf1Public ( �1--1.Other f-1 Delta Depth of Grout Seal Type,of Grout - 1 Irrigation __Approx. Depth I I Eastern Surface Seal Installed by 4 _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION i 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other t 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. ❑ Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS ❑ 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, an 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 pers in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub=contracting signature certifies the f'If w' g: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen tion lawsrnia." The apl ust call for all req 'ed inspec i ns. Complete drawing on rave se side. Signed X Title: ` Date: �� 1in DEPARTME T USE ONLY Application Accepted by Date A0 J Ar d s Pit or Grout Inspection by Date Final Inspection by Date 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 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY --PATE PERMIT'1V0. +.EH1 ' � 144-28 24[REV.i i n 51 EH � ?b�b I