90-3303 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PAYMENT li PERMIT EXPIRES 1-YEAR FROM DATE ISSUED RECEIVED l (Complete in Triplicate) DEC T jg Q !c Application is haieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules ant�@g+#{atlgq$pf the San Joaquin Local Health District. ii ENTAL HEALTH itR PERMIT f SERVICES Job Address Cityf Lot Size PM d; Owner's Name _ _.__ tf"rs , Address / , �L �--� Phone Contractor Address 0 - License Nom Phone ;E TYPE OF WELL/PUMP: ;� NEW WELL ❑ WELL REPLACEMENT q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTAE WELL OTHER WELL PITS/SUMPS r t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications j ['I Public ❑ Other C] Delta Depth of Grout Seal Type of Grout _ a I I Irrigation —Approx. Depth I 1 Eastern Surface Sea! Installed by A _ Repair Work Done f Type'Pof Pump 4 H.P. _ State Work Done Ar Well Destruction ❑ WeII Diameter Sealing-Material (top 50'i x Depth Filler Material (Below 601 f1 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.) i Installation will serve: Residence_ Commercial_ Other Number of living units: '! Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ n f Method of.Disposal Distance to nearest: Wel I. Foundation Property Line LEACHING LINE ❑ No. & Length of lines Try 1. ^Total length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line j SEEPAGE PITS 11 Depth _Size '- _ Number SUMPS FI Distance to nearest: Well Foundation Property Line., DISPOSAL PONDS ❑ 1M 1 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.. 1 Home owner or licensed agent's.signature certifies the following; "I certify that in the Aerformance 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 F 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 applican st cal all required inspections. Complete drawing on`r�rse side. 1 Signed X ' .. Title: i Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date / 7&' Area Pit or Grout Inspection by I� Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 Applicant - Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERMIT NO. INFO �j CASH / z�aj f + EH 13-24(REV.i/n5) r d� 3�//� j / �� EH 14-28 t I! I