90-265 - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.., STOCKTON, CA Telephone (209) 466-6781 11\ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 r Local Health District. J� � / /rnr Job Address rstpt`�a x-�� City ►L�d�t S , Size `� �l�'is]PM Owner's NameAddress Phone Contractor I ddfess License No. {k J� Phone TYPE OF WELL/PUMP: NEW WELL iQ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IM 14- SEWER LINES 1004 V DISPOSAL FLOPROP. LINE FOUNDATION AGRICULTURE WELL. � 2( OTHER WELL - PITS/SUMPS �- I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private VLGravel Pack ❑ Tracy Type of Casing Specifications , f f1 Public iI Other Ll Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by h - Repair Work Done � Type of Pump C .._ H.P. 3 State Work Done_ �} Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is N ti Q� available within 200 feet.) - c Installation will serve: Residence— Commercial_ Other1V , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg yCapacity - No. Compartments PKG. TREATMENT PLT. ❑ `' -. Method of Disposal r" 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 SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicationand 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 Di§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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub,contracting signature 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." i The applicans ca I for all rrm d Inspection;. Complete dr ng on reverse side. y! Signed17 7itfe: �� 7 Date: r�" ��`�o EPARTMENT USE ONLY Application Accepted by cob 4A (,,l11Date Area F Pit or Grout Inspection by Date Final Inspection/bey Date Additional Comments: �� r✓r / ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ] Cy 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95203 - -- - FEE "'MOUNT-dUE -_---AMOUNT REMITTED' ..- -GK RECEIVED BY T DATE PERMIT NO. INFO CASH I ! B� 9 +.EH 13-24(REV.t i H 5Y f r 1 / �� !^�