90-2968 - Laserfiche WebLink

Home Browse Search

r � t. 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. a C Q Job Address r-�/� S 9#4 T �� - City �j.Po� Lot Size PM , Owners Name P 0 V & DV' Y AV Address ! SA�/��5 Phone I' Contractor �ie++r d $p�f Address Op �G a v''� d'� License No.yy� Phone TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! 5 ecifications LiDomestic/Private �❑ Gravel Pack ❑ Tracy Type of Casing P r ["1 Public ;Cl Other ❑ Delta Depth of Grout Seal Type of rout _ I I IrriA Depth I 1 Eastern Surface Seal Installed by - gation tea � _-Approx. p Repair!Work Done ❑ 1 Type of Pump H.P. State Work Done Well Destruction ❑ ;Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:i NEW INSTALLATION _.REPAIR/ADDITION 11.-DESTRUCTION I I (No septic system permitted if public sewer is y I t available within 200 feet.) Installation will serve: ' ,Residence ;Commercial ° Otherti Number of living units!� — Number of bedrooms Character of soil to a depth-of 3 feet: Water table depth SI=PTtC TANK �* Type/Mfg p1R° p{4 Capacity l Loo No. Compartments PKG. TREATMENT PLT ©_ I Method of Disposal Distance to nearest: Well Foundation 0 Property Line 1 r I LEACHING LINE 0 No. & Length of lines 3 > D If .Total length/size A VC FILTER BED ❑ Distance to nearest: Well 4a Foundation -y Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L1 Distance to nearest- Well Foundation Property Line DISPOSAL PONDS ❑ 1hereby 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 Iowner 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 mus call for all required inspections. Complete drawing on reverse side. I Signed X i Title: Date: G + R DEP 7IMENT SE ONLY Application Accepted by 1 Date -O O Area I Pit or�Grout Inspection by Date Final Inspection Date/i;� I Additional Comments: D 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 I i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. +.EH1324(REV.s/tA � �aC EH 14-2a