90-1282 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Gar 7r� L 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address // T /p /�' / ��f✓ 'Ou',f e. City. Lot Size 1<n PM Owner's Name �4� d d r e s s "� / ��V Phone Contractor Address 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 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other f] Delta Depth of Grout Seal Type of Grout I I Irrigation ___.._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done S Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i 1 (No septic system permitted if public sewer is '/ [,� � available within 20D feet.) Installation will serve: Residence_ Commercial '! Other -5^�� }_ Number of living units: Number Iof bedroomsh A+��.rtmt.-% (s!i -bt ) f �)f Character of soil to a depth of 3 feet: Water table depth o�O SEPTIC TANK C Type/Mfg Q Capacity `,Zb C� No. Compartments PKG. TREATMENT PLT. ❑ h` �4X tMethod of Disposal Distances to neare Well ;) O� Foundation DC7 Property Line q .Z O LEACHING LINE Wy Ko. & Length of lines I)4hc::�' total length/size FILTER BED ElDistance to nearest: Well 17-Li Foundation c�5� Property Line J47 t SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 Doltrict. Home owner or li nsed agent's signature cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per in such m er as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies the fol ng: "I c If hat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of li rnia." The app ca call or d ' tions. om drawing on reverse side. ` Signed X Title; Date: v IF O U5E ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Date If, Additional Comments: ❑ Stk 466-6781 ❑ Uodi 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 INF MOUNT DUE AMOUNT REMITTED CCK RECEIVED By DATE PERMIT'NO. 4+.EH13-24IREV.I/Hsi Q .off �� ld 10-1 EH 14-2e