90-2765 - Laserfiche WebLink

Home Browse Search

f APPLICATION FOR PERMIT 1� SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA w� Telephone (249) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 c City Lot Size � PM Owner's Name Address ^ Lp21 Phone Contractor Address c se Ko Phone TYPE OF WELL/PUMP: NEW EL WELL REPLAC ENT DESTRUCTION ❑ ---PUMP-INSTAL Tl NF -S_Y_ T -REPAIR - � r--.T- ER-0 DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FLD ROP..LINE FOUNDATION AGRICULTURE WELL k OTHER WELL A / PITS/SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTIR UC lOECIF N SP ��ONS !/ ❑ Industrial pen Bottom ❑ Mantec�&U- Dia. of Well Excavati Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Manteca of Casing Specifications FI Pu , n Other it Delta epth of Grout Seal Type o rou Q . I rrigation �..Apprax. Dep h 11 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H;P's - 7 State Work Done T Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ' Installation will serve: Residence_ Commercial— Other 1A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table dep1 th SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �. SEEPAGE-PITS -1-1-=t)epth----- �5' _ a' "----=Number - SUMPS Ll Distance to nearest: Well Foundation Property Lirle 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 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 laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that' 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 applic t calf fo all re d ins ctions. Complete drawing on rse tFO Signed X Title: ` Date: vk R DEPARTMENT USE ONLY y Applicatio Accepted by Data Area r mac-�, /� _ Pit or aro inspection by /�"- Uat "!"�` Final Jnspection by7 I X� DataG Additional Comments: ❑ Silk 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMt7'NO. INFO CASH + EH13-24(REV.i/x 51 EH 14-26 G