90-2058 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT t { SAN JOAQUIN LOCAL HEALTH DISTRICT U L 3 0 1990 z 1601 E. HAZEL T ON,AVE., STOCKTON, CA Telephone (209) 466-6781 ENWRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ PERMT/SLRVICES (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 16 d. City Lot Size PM III Owner's Name ` Address Phone 1 r� t Phone_ Contractor l �— Address 5 > License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 71 ! PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ DISTANCE TO-NEAREST%�SEPTlC�TANK�... SfWER,LINES_ �. _ DISPOSAL FLD. PROP- L- INE r € FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L, 71 Public ❑Dther ❑ Delta — Depth pf-Gi0ut Seal ' Type of Grout'f I I Irrigation _.-Approx. Depth t I Eastern Surf ce Seal Installed by - n Repair Work Done ❑ Type of Pump H.P. I State Work Done e�J Well DestructionC] Well Diameter ' Seali6g Material Itop 50'1 £ Depth 114 Filler Material IBeiow 50`I -- TYPE OF SEPTIC WORK: NEW INSTALLATION'I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.] F ._ __v .} Installation will serve: ,Reside. nce_x.._._ Commercial_ Other _ Number of living units: Number of bedrooms d Character of soil to a depth of 3 feet: ' r` - -- Water table depth SEPTIC TANK. O Type/MfgI F Capacity No. Compartments T ; PKG. TRI ATMENT PLT-'❑ Method of Di§pbial .�... M Distance to nearest: Well Foundation F Property Line LEACHING LINE I❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'.nearest: Well Foundation Property Line k 1 SEEPAGE PITS p I 1 Depth Size Number z '��Sl9MPS"�" "�"�"' Ll Distance to nearest: Well Foundations ---=—"'_-'-Pro PertY--Line DISPOSAL PONDS ❑ 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 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 shall not employ an such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the folio in : "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion law ia." f ,4 The appli t call for all req r inspectio Complete drawingArver side. Signed Title: Date: i 7 FOR,DEPARTMEN USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b 7� Date Additional Comments: C] Stk 466-6781 M Lodi 369-3621 r 1 ❑ Manteca 823-7104 fl Tracy 835-6365 s Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j Y L- t FEE AM UNT DUE: AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I INFO CASH �::; +.EH13-24[HEV.]/HSY g,F-✓ L) 70.20"'1 �