90-1510 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR 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. Job Address 6 Owner's NCity Lot Size PM Sa.� r Name /� Address v/ Phone t TYL/ Gantractor� �GG 'f'`"'fgddress q TYPE OF WELL/PUMP: License 1Vv. -u _! 5/69 NEW WELL ❑ �—Phone q WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION , SYSTEM REPAIR t DISTANCE TO-NEAREST: SEPTIC TA , - -- NK �—� SEWER LINES OTHER LJ- FOUNDATION E?1SP05AL FLD_ �P_ROP.•LfNE —�� AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PiTS/SUMPS PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial ❑ Open Bottom �- ~ ❑ Manteca Dia. of Weli Excavation Domestic/Private D Gravel Pack Dia. of Well Casing ❑ Tracy Type of casing Public ❑ Other M Specifications f7 Delta Depth of Grout Seal I i Irrigation _--Approx. Depth ( I Eastern Type of Grout Repair Work Done .9 Surface Seal Installed by Type of Pump H P Well Destruction ❑ Well Diameter —� State Work Done LlCe° Sealing Material (top 50'I Depth_- _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.'1 REPAIR/ADDITION LI DESTRUCTION E I fro septic system permitted if public sewer is Installation will serve: Residence I- Commercial Other available within 200 feet.) .� , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity— No. Compartments Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Wel! Total length/size q Foundation Property Line SEEPAGE PITS I I Depth I Size " 'rte 'SUhIIPS'--- -`! ❑ Number "'trDista`nce'to'nearest:"""^CNell'"'� '" �..,.,.� DISPOSAL PONDS ❑ FoundationProperYy - �," 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 Di$trict. Home owner or licensed agent's signature certifies the following: I Ho employ an g: '"i certify that in the performance of the work for which this permit is issued, I shall not R y y 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 call fo�allr ire inspections. Complete drawing on reverse side. , r_ Signed X /'1 � Pi1G• Title: LQYk/ g,0 r r Date: PO R PARTiVIENT USE ONLY r Application Accepted by Pit or Grout Inspection by bate Date Area Final Inspection by j G Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-&385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i t FEE [- DUE AMOUNT ! INFO � AMOUNT REMITTED CK RECEIVED BY -•y J-71 {CASCHy GA;TE PERMIT�Np. I ♦.EH 13-24{REV.i i n 51 `.� �_ Cr— V 7 / /� `/�]EH 11-28 V ! -90 f V —/�/11