90-499 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. .�I Job Address 200 C /L City S°7 YU✓ Lot Size _4�-'Q(f PM �— f Owner's Name 4(4--7"S,_,_...I!✓C Address 17,7-1 )1. Phone `q-d� 167�7_411 Contractor 49 yC) E:- &/010Z1_Address 2.6/, License No. =Y E Phone TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PLIIMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ it DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;i. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .!i ` f`1 Public [.1 Other F7Delta Depth of Grout Seal Type of Grout I I Irrigation 11..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done:_ 41 Well Destruction ❑ WeiII Diameter Sealing Material /top 50') Depth Filler Materia! (Below 50') _ l� TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITIONDESTRUCTION I I INo septic--system permitted if public sewer is ly available within 200 feet.) 4 Installation will serve: Residlrence_ Commercial Other Number of living units: II Number of bedrooms Character of soil to a depth of 3 feet: C"I-/J e Water table depth SEPTIC TANK ❑ Type/Mfg 4:-,Y)STi.a/� Capacity No. Compartments F1PKG. TREATMENT PLT. Method of Disposal I Distance to nearest: Well Foundation Property Line. LEACHING LINE No. & Length of lines _ l O-"C7 Total length/size i 4G' FILTER BED ❑Distance to nearest: Well0 Foundation o Property Line /OD I SEEPAGE PITS I'1 _De th �a r ~ � I P _Size Number v2- SUMPS Ll Distance to nearest: Well -7, Foundation t1j. 4a% _ Property Line: lWev DISPOSAL PONDS ❑ .I1 —` "- i hereby certify that I have prepared this application and that the work will be done in accord_a_nce 'With San"Joaquin,county ordinances, state laws, and F rules and regulations of the San Joaquin Local Health Diatrict. ^-r { Home owner or-licensed agents.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 hieing Cr sul:con`tPacting signature certifies the following: "I certifythat 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." The applicant must call for all required inspections. Complete drawing on reverse side. P 9 I Signed X__ �![.mss Title: _ t Date: 3 i FOR DEPARTMENT USE ONLY Application Accepted byDate 3"`1 'D Area f S&.k� Pit or Grout Inspection by II' Date Final Inspection by Date 3 Additional Comments: ❑ Silk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant__Return all copies to: Environmental Health.Permit/_Services 1601 E._Hazelton,Aye„-P.O,_Box,2009,_Stk.,_CA 95201-- INFO ib FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. +-EH 10-2e(REV.t i 9 51 , 0 I s-i e -