90-381 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DiSTRfCTR, '" t} jamw. 1601 E. HAZELTON ON AVE., STOCKTON, CA F Telephone (209) 466-6781 FEB 2 0 F�{q PERMIT EXPIRES 1 YEAR FROM DATE ISSUES fVdRONfNTAL HEALTH (Complete in Triplicate) �, �r� P P ��'ATde�&W lication is Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the wor err a PP 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 Addres � 44,E r6 6 City Lot Size PM Owner's Name', •1/ l Addres Phone�� Q� 1 I Contractor ZAddress � � License No ,G o4.3�3_--Phone TYPE OF WELL/PUMP: NEW WELL ElWELL 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 GYlndustrial ❑ Open Bottom ❑ Mant6ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ElTracy i Type of Casing': Specifications i 1 1 Public ❑ Other [71 Delta Depth of Grout Seal Type of Grout _ i I Irrigation ---Approx. De l I astern Surface Seal Installed by Repair Work Done Ly Type of Pump H.P. �I ®`� State Work DoneOF �1 Well Destruction- ❑ Well Diameter Sealing Material (top 50') Depth •j Filler Material [Below,501 I — TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence_ Commercial— Other tt Number of living units: Number of bedrooms 4 � s Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity l No. Compartments I PKG. TREATMENT PLT- Ll Method of Disposal Distance-to-nearest: Well foundation y 'Property Line LEACHING LINE ❑ No. & Length of lines € Toial length/size ► FILTER BED ❑ Distance to nearest: Well Foundation Property Line i i j l SEEPAGE PITS l I Depth Size Number 1 SUMPS Cl Distance to nearest: Well Foundation i Property 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. 1 I 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." 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;1 shall employ persons subject to workman's compensa- tion laws of California." i The applicant u tail for all equired inspections. Complete drawing on reverse side. it f' Date: ` / Signed X ,Title: I OR DEPARTMENT USE ONLY r Application Accepted by Date '- Z � Area 2 Pit or Grout Inspection by Date Final Inspection Dal.Z Additional Comments: ❑ Stk 466-6781 ❑ 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 Il FEEAMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. INFQ 1* +.EH 13.241REV.I/A$) Z� � ��{ p EH 14-28 4