90-366 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L'1601,E. HAZT ON AVE., STOCKTON, CA -—Telephone (209) 466-6781 PERMIT EXPIRES, TYEAR 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District, Job Address t V f cf:.= fl11t�`I n-4y n LIQ� City ' Lot Size PM '77-7 lt"t' . � r 6•. �1t' f" '✓ Owner's Name,. Address Phone ss. Contractor ! .J1.3 1. C f FG' Address .. F, r7lYI'LT7!� License No. 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 --. .._.. �-.. _ - - -'�FOUNDA-TION___.. AGRkCULTURE 1NECl '" - " OTHER-1NELL -" i-PIT5ISUMP5 , INTENDED CTS_^_—" TYPE_}F WELL-"-PROBLEM AREA—CONSTRUCTION SPECIFICATIONS ❑ Industrial LJOpen Bottom © Manteca Dia of Well Excavation' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack I 'Ll-Tracy Type of Casing Specifications FI Publicr" - Depth of Grout Seal � Type of Grout +!� 1.1 Irrigation �%t:App�ox.-Depth._ t Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ _ Sling Matarria'eltop 50,) 7r r filler Md erial (Belo 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIFUADDITION.iJ DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ ComrftercibI_ 'Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmentsla PKG. TREATMENT PLT. ❑ ' 4 Metflod of Disposal Distance to nearest: Well Foundation Property Line ' i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I ) Depth Size Number SUMPS L1 Distance to nearest: Well foundation Property Line' ,. .i 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, ander rules and regulations of the San Joaquin Local Health Df�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 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 of California." 1. The applicant must call for a wired inspections. Complete drawing on reverse side. ` r 'arr � t 16T°' 5ignedaC. t,E .r Title;—, - - Date: . FOR DEPARTMENT USE ONLY E Application Accepted by Date Area Pit or Grout Inspection by f f n Date Final Inspection by �O I Date4/v Additional Comments: 0'tyv to mo-tL � "re �`��tf SGys L,00.-Ir-M; Cora. C) c less CLr ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 w45 a K S r 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 RECEIVED BY DATE PERMiT'NO. INFO +.EH 13-24(REV,FiHSI �� -3kn EH 14.29 i