90-84 - Laserfiche WebLink

Home Browse Search

h APPLICATION FOR PERMIT oll SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209}.466-6781 'I 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. " r Job Address D 1_"C ity Lot Size PM Owner's Blame 0 -ss t` ` Phone Contractor nse No, v 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 ❑ Public 1-1 Other ❑ Delta Depth-of-Grout-Seal Type of Grout I 1 Irrigation -Approx. Depth i I Eastern ; Surface Seal Installed by Repair Work Done ❑ Type of Pump- H,P, State Work Done r t i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ff REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is f I available within 200 feet.) Installation will serve: 'Resildence! Commercial �" Other Number of living units: ! Number of bedrooms s Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .moi Method of Dis osal Distance to nearest: Well fi9- •••-•-Foundation'—�_�__ Property Line_..��_(�_ LEACHING LINE ❑ No. & Length of lin `"� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f` Property Line SEEPAGE PITS l P Depth Number SUMPS L1 Distance to nearest: Well © Foundation ® t" Property Line _ ; DISPOSAL PONDS ❑ ; IL. I hereby certify that I have prepared this application and that the work will be done in accordarice witK San Joaquin county ordinances, state laws, and. rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work`fo 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." The applicant m s c r all I1 quired i pe tions. Complete win on revs de. ase P 9 ///Signed X Title: Date: FOR DEPARTMENT USE ONLY. y Application Accepted by Date d Area Pit.or Grout Inspection by J Date 1 Final Inspection by Date , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 I❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Sik., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 1 -241REV:_1/1i51 yl` —! ,u e .� EH 144-29 � y' Y