90-788 - Laserfiche WebLink

Home Browse Search

i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 3 YEAR FROM DATE ISSUED ECEI (Complete in Triplicate) VE ENVI MAY 1990 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein sl�1*T li n is r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R 10 by fES + Local Health District. �5ERVIC J Job Address �3 2 of ,K Sif 6 �A & City Lot Size PM/T Owner's Namey L�� Es Address 0u r Phone �u f r F Contractor �C' Address to�� L.Cn / L� cense Na*� Phane36 TYPE OF WELL/ UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR)14 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' =- -AGRICULTURE-WELL OTHER-WELL ---- PITS/SUMP5 _- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 177 Public F1 Other Cl Delta Depth of Grout Seal Type of Grout _ JK Irrigation =_'Approx. De th i 1 Eastern Surface Seal Installed by _ Repair Work Done 171Type'nf Pumplf shy H.P. f � State Work Done�a" }' Well Destruction ❑ `"W4JI,'Diameter Sealing Material [top 50') ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth {)J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propdrty.Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'] Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS❑"`�f 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, an 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 4 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 must call r all required inspections. Complete drawing on reverse side. Signed X Title. — Date: �_A _7Q 0 I FOR�]DEPARTMENT USE ONLY c� Application Accepted by Dated r Area t Pit or Grout Inspection by Date Final Inspection by Da Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RE=CEIVED BY DATE PERMIT No. r +.EH 1324 iREV.1 i n 51 Li/ F EH14-28 47 d i ice.