90-368 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (Complete in Triplicate) 40-f-10 ; Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicati n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address In l °: l +t 13"J tf f'1 ,_ City 1571e k2'"£lr"...I Lot Size PM Owner's Name f72t1*--=, -`r Ole:l 6 Address i ! .'r., .�' � 7 a1`3 L l fw d.� Phone !. *ems�:&D ContractorAddress 7.•.�_ r ?"' YrL_-f` r'� �' ;�-� �' � 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'S, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /" f3frt Dia. of Well Casing i,' I 17 Domestic/Private LJ Gravel Pack-+— L1 Tracy Type of Casing's Specifications F Public 1 r,. N'Other 7 •!,! r �,f`[�pelta Depth of Grout Seal Type of Grout _. I I Irrigation ff, hpprox. Depth l I Eastern "Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P. - State Work Done 1 uctWel[ D7tr )iW Pram ler Sealing Material (top 50' 1 / Zl f Filler Material l6elow 50') _ F TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION [ I DESTRUCTION l I Wo septic system permitted if public sewer is j available within 200 feet.) I , Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Characterofof 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth Size _ Number i SUMPS Ll Distance to nearest: WellFoundation 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, and rules and regulations of the San Joaquin Local Health D3trict. 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all.arequired inspections. Complete drawing on reverse side. Signed X n brtE .t.s .r\ Title: I 1 I.< !¢�, Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ''°,lJ Area a�7 Pit or Grout Inspection by Date Date /Final flff�Spe tion �y � I" V ve TC] 1C�, ili JIT !;a ,rbP� w44 , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy -6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE 3 1F' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1;-24 4REV,1/H 51 i C. EH 14-26 r O f i