90-177 - 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./ q Z r�t— )Job Address �p City Lot Size PM Owner's Name t . �/ Address 79Zf-All &A�"Phone Contractor f44LAW 16ANSTA-PAep dJ�i� License No.�! 12J24'Phbne 71 TYPE OF WELL/PUMP: NEW WELL ❑ VXLL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ STEM REP IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE EL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS (Q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. f ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of C sing Specifications M Public I l Other Cl Delta epth of G ut Seal Type of Grout I I Irrigation —.-Approx. Depth f I Eastern Surface Seal nstailed Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter S 'ling Material (top 50') vr. Depth eller Material 16elow 50'1 S TYPE OF SEPTIC WORK: NEW INSTALLATION RE AIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is r .. .s available within 200 feet.) Installation will serve: Residence " Commercia'l. Other Number of living units: J_ Number of bedrooms 11T Character of soil to a depth of 3 feet: L PAIAI• Water table depth SEPTIC TANK ❑ Type/Mfg - �/` _:_' Capacity-( No. Compartments PKG. TREATMENT PLT. ❑ n Method of Disposal Distance to nearest: Well_A��oundation-Z8PF'__r. Property Line LEACHING LINE ❑ No. & Length of lin ~� Total length/size e FILTER BED ❑ Distance to nearest: Well ZS�O Foundation , f3� Property Line S t SEEPAGE PITS I I Depth Size Number ? SUMPS ❑ Distance to nearest: Well Foundation 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. 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 !i 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 for all required inspections. Complete drawing on reverse side. I Signed X e , A Title: � �+ Date: .� A t4 17 OR IZEEARTMENT USE ONLY m Application Accepted by , `� _ Date W Area Pit or Grout Inspection by Date Final Inspection by Se. Additional Comments: ❑ Stk 466-6781 CI 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 ! INFO AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMIT'NO. 1 +.EH 13-2+]REV.I/H 5) 0_3Ai;:-7 Y 11 - EH la-2tS � �