90-2541 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ,� �� SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 � �IIRON .TAL HEAL -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - PERMITl$Z.R� Q (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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � �O (�A ' City Lot Size PM t Owner's Name n�Address �-�lt--��.�� Phone Contracto •--� Address'i�±- ,��v t ��ay License ND! 3 Phone's; `_2�/ j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DEST'RUCTION_❑T ,,..- ...,.�,.....• "" ,.�... PUMP INSTALLATION CX SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing b(DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing �' Specifications r'1 Public (7 Other ' 17-1 Delta Depth of_Grout Sean 'Type of Grout _ a I I Irrigation y� --Approx.. Depth l 1 Eastern Surface Seal Installed by J Repair Work Done I�Type of Pump ._—... H.P. (1FY-9L� State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material )top 501 r Depth Filler Material {Below 50') - Il TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION [ 1,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:'1 Water table depth n SEPTIC TANK ❑ TypelMfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 'I Method of Disposal Distance to nearest: Well Foundation Property Line [1 LEACHING LINE ❑ No. & Length of lines Total length/size T� FILTER BED ❑ Distance to nearest: Well Foundation Property Line _, _ 1, _. _-•�' - - -—Number -^ ---. - SEEPAGE PITS- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ hereby certify that I have'pfepared'this 8pplication+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 signaldre certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 1iI employ any person in such manner as to,become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sign awre 'r 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." r The applicant must call r all required inspe tions. Complete drawing on reverse side. c ` Signed X Title: L-1-1 Date: FOR 01EPARTIMENT USE ONLY Application Accepted by Date Area ...,..., - .e _ � �D r0 �lv Pit or Grout Inspection by Date Final Inspec'tiori bye Data y 1- 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 AMOUNT DUE"t AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH13-24iREV.1i8s1 q o o X54 EH 14-26 t