90-314 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address l c5 ! -5Gc•�/ �.Y Al / City l Lot Size PM Owner's.Name 1 t ��5 Address G' Phone j Contractorf.�[ r: Address Yt r'J License Phone k- _j�Y.PE_.OF_WELL/PUMP:- ,�. _ _ . NEW WELL -❑_ WELL REPLACEMENT ❑ DESTRUCTION_ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, EINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 7. 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 El Tracy Type of Casing ' Specifications (`l Public (7Other f-1"Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by _ 3 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'J f- Depth Filler Material (Belo ') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION bef DESTRUCTION € I (No septic system permitted if public sewer is I I— — available within 200 feet.) Installation will serve: Residence Commercial Other *, ` Number of living units: Numbertof bedrooms 2 I �. ' J Character of soil'to a depth'of 3-feet:, —_� �1� �-_� � Water table depth # SEPTIC TANK ❑ r Type/Mfg �^�—� - Capacity ,fi No.Compartments i : : PKG. TREATMENT PLT. 1-1i {. � Mett;od of Disposal f 'Distance to 'earest: Well'. —..Foundation; Property Line LEACHING LINE Vr No. & Lengt;of lines - � T?tal length/size FITTER BED LJDistance to nearest: Well_.-. �.,,_ Fbundation�_ Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation —Property-Line— DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature I certifies-the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work an's compensa- tion laws of California." The applicant must call for all-re i e -inspections-.Complete-drawing•on-reverse side. Signed f Title: �" _ Date: ( V n+ Ffl1ENTY_52 ONLY i `J Application Accepted by ... �Jl� Date Area ' moi• . •- ,. Pit or Grout inspection by Ni Date Final Inspection by Dat } Additional Comments: ❑ Stk 466-6781 ❑ Lodi-_369-3621. • C] Manteca- 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. -EH t3-24(REV.i EH4-26ID