90-212 - Laserfiche WebLink

Home Browse Search

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 (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 I / ryV City Lot Size ` PM 1 Owner's Name r_)1-r6 Z_'e UV 1r_ Address L14-- F Phone 41 / /�� ' Contractor a_w e'er, Address License No. Phone_ V YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR TION SPECIFICATIONS ❑ Industrial CJ Open Bottom ❑ Manteca Dia. of Well ovation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public f] Other H Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Easter Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- \ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR)ADDITION l I DESTRUCTION ! (No septic system permitted if public sewer is } aitable within 200 feet.) Installation will serve: Residence— Commercial _ Other ('a Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I-] Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth . I Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, ands . rules and regulations of the San Joaquin Local Health District. �Vl 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 notes`.' 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for all r qui red " 0 cctions. Complete drawing on reverse side. 11 KS igned X /2��) . Title: Date: ± FOR DEPARTMENT USE ONLY t Application Accepted by Date ` �� Area Pit or Grout Inspection by Date Final Inspection by'T'� Additional Comments: Ll Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. IN t + EH 13-24tR EV. 51 EH 14-26 -�J