90-529 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 �a�s Fa�z City -- Lot Size PM I Owner's Name W�7eS/c )e'AIZ, AddressPhone 9elxoa 1 Contractor Address 1-6,,(�dJf a icense No. Phone k�6a`-72 Z, 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 F] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation __-Approx. Depth.. I l Eastern. Surface Seal Installed by - Repair Work Done ❑ Type of Pump `� ` H:P. State Work Done Well Destruction ❑ Well Diameter* _Sealing-:Material Itop 501 yt Depth t Filler Material (Below 501 — d TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A Commercial— Other Number of living units: Number of bedrooms" a Character of soil to a depth of 3 feet: I �- Water table depth ,q SEPTIC TANK 1A Type/Mfg l'"#4 4DVCh1-tL Capacity L2'06 No. Compartments �- I PKG. TREATMENT PLT- ❑ i Method of Disposal Distance to'nearest: r Well ,O/A= Foundation ZP Property Line 242� LEACHING LINE ❑ No. & Lehgth of Dries` Total length/size FILTER BED_' ❑ Distance lance to nearest: -Well Foundation° � Property Line 4 SEEPAGE PITS , I I Depth Size ~ Number SUMPS A L] Distance'to nearest: Well Foundation Property Line DISPOSALS PONDS ' ❑ > I hereby certify that I have prepared thi's application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaauin_Local Health Di§trict. Home owner or licensed agagenC.signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subiect 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." s. The applicant must call for all required inspections.;6ornplete drawing on reverse side. Signed X Title: ��/ Date: l FOR [DEPARTMENT USE ONLY Application Accepted by Date v"� a-cb Area t Pit or Grout Inspectio Date Final Inspection by Date Additional Comments ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E.Hazelton,Ave. , P.O,-Box 2009;Stk., CA 95201 ..� " � - `. FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO t EH 1 -24rREV,tirs5l `�� It�.„S 3/1�1�10 c1o`��. I EH 14-Za