90-1586 - Laserfiche WebLink

Home Browse Search

k `{ i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I 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. i ] Job Address f ` + r d City OA 1—T Lot Size �•� C. PM {f f Owner's Name �1/�1' �— Address �Ci 514 oV C'f i 1 Phone 3_74 S r 3a hk'AA A— A Contractor4jaa;& Address �P 'a 3 f MOO" License No.,199 �� Phone 7 457 TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK &0 SEWER LINES 100 DISPOSAL FLD.�50 PROP. LINE _VZt FOUNDATION i.SL1 AGRICULTURE WELL OTHER WELL` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 f -❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing . { j Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i ljrZ7-Lf Specifications + F1 Public 171 other F1Delta Depth of Grout Seal -,fes 1-0c7 Type of Grout _ ' I Irrigation 04AI-.Approx. Depth 1 l Eastern Surface Seal Installed byf�leads g-11 l;3 r I Repair Work Done ❑ Type of Pump Sa E7 _._ H.P. ✓ State Work Done Weil Destruction ❑ Well Diameter Sealing Material flop 501 g S.A 4 Al Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIAODITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other C Number of living units: Number of bedrooms C 1 Character of soil to a depth of 3 feet: Water table depth Q2 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 0 I PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation Property Line f n a V1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line x SEEPAGE PITS l I Depth Size _ Number SUMPS Ll 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 Dibtrict. 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant 79st call 1prail re fired ins tions. Complete drawing on reverse side. - C LCe/w _ Signed X Title: �� Date: EPARTMENT USE ONLY ` Applicati93 Accepted by Date S0 Area Pitr rout spection Date Fin I Inspection � crcr o.)tDat ~ w Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Man 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Heap# ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 „{ K 4 FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. INFO / J - a +.EH13-24IREV.1/n51 to �= : jnrj EH 1428 ell VVV .. �O