90-2663 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT -' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ribed.This cation is Application is hereby made to the San JoaquinJoaCounquin Locaealth District for a permt to construt and/or install the work herein dese tyOrdinalnHe No.549 for sewage or INo. 1862 forcwell/pump and the Runes and R gulationss of the Sans Joaquin made in compliance w Local Health District. r 11 iiiP Lot Size Q � PM City S Job Address —W— Phone"" _ S Phone " i Owner's Name -� Address , r `0 gess b /f� License No:-3�_ �Phone D� Contract TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ SYSTEM REPAIR ❑ 1, 1 LJ PUMP INSTALLATION ❑ DISPOSAL PROP. LIN SEWER LINES __--- SAL FLD. E _ ' DISTANCE TO NEAREST: SEPTIC TANK � I FOUNDATION AGRICULTURE WELL OTHER WELL PlT51SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial © Open Bottom El Manteca 11� Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing.F - ❑ Delta Depth of.,Grout Seal r '� F Type of Grout i-I Public ❑ Others , - Approx. Depth 1 I Eastern Surface`Seal Installed by l I 1 Irrigation - f Repair Work Done ❑ Type of Pump H.P. r Stare Work Done Well Destruction ❑ Well Diameter SeYafingMaierial )top 501 f �_ Filier Material (Below 50'1 Depth - UCTION I I' TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REP.AIRlADDITION DESTRaNaifabetfwithin 200 feet' if public sewer is Installation will serve: Residence Commercial, _Other t Number of living units: Number of bedrooms" I (� Water table depth Character of soil to a-depth of 3 feet: i ❑y, -Type/Mfg Capacity No. Compartments SEPTIC TANK Method of Disposal j PKG. TREATMENT PLT.❑ rs 'Property Line Distance to nearest: Well Foundation P Y " li (] Totallengthlsize LEACHING LINE No. & Length of lines FILTER BED ❑ Distance to nearest: Well l Foundation_--0,'Property Line S Size~ Number SEEPAGE PITS Depth Q c Pro art Line 5 SUMPS ❑ Distance to nearest: Well! Foundation _-�� P Y DISPOSAL PONDS ❑ and San Joaquin county ordinances, state laws, and that the work will be done in accordance with I hereby certify that I have prepared this application 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 for which this permit is issued, l sign not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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� I tion laws of California." The applicant must call for all required pec ions. Complete drawing an reverse side. I Title: Date: Signed X FOR DEPARTMENT USE ONLY I _/ Date_{a: �-�7 U Area 2� pplication Accepted by ..` � f�`a� Dat 0- p - ^amu �YY� l?�, Date �... v Final Inspection b Pito Grout inspection by /.- Additional Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 r Applicant Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. ffEZ AMOUNT REMITTED CASH � o �EH 13-24(REV.fi e 5)EH 14-26