90-1109 - Laserfiche WebLink

Home Browse Search

E+ 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 i' I (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. , f Job Address JiS,/ s I'.i ` �r "�"�e ize PM � r r Phone Owner's Name dress �� r s � iL'icense No. / Y Phone �,Y1' a t ar TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK > SEWER LINES DISPOSAL FLD. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFMWELL PROB�EbA AREA CONSTRUCTION SPECIFICATIONS w ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public Cl Other ' Cl Delta `` Depth of Grout Seal Type of Grout 1,1 Irrigation �_..Approx. h. Ea rn �!��_ Surfac stalled by - I Repair Work Done ❑ Type of Pum P t State Work Done _ Ir r Well Destruction ❑ Well Diameter Sealing,Material (top 50') Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is f9 available within 200 feet.€ t Installation will serve: Residence Commercial— Other,'i -S f Number of living units: Number of bedrooms Ij / Character of soil to a depth of 3'feet: I /+ Water table depth SEPTIC TANK ❑ Type/Mfg ,1 !^ Capacity No. Compartments PKG. TREATMENT PLT. ❑ t i Ca Method of Disposal 0 Distance to nearest: Well fel Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size S # FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS [ I Depth Size f Number SUMPS Cl Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS C] - = �i-hereby certify-that f have-prepared this application-and that the work:will be done in accordance.-with San Joaquin county_ordinan6's state laws, and rules and regulations of the San Joaquin Local Health D€§trict. .a 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 r 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 forlwhich this permit is issued, I shall employ persons subjecf to workman's compensa- tion laws of California." „�,.T '- cl.� The applica t ust call far all required insspectioas C pladr winglonZr , rse side. +"`; E' "` tom Signe itl Date:a w� �'. 00 FOR DEPARTMENT USE ONLY Application Accepted by ' f Date ` Area i r'f� `r' i ^i Pit or Grout Inspection by Date Final Inspection by.s ` Date � Additional Comments: \ S• *.` -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 " +\ t Xa Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ( AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.I/H 5) l EH 14-2e