90-407 - Laserfiche WebLink

Home Browse Search

4PPL1CATION 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 ICornplete 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 l ' C44 Lot Size PM Owne s,N'.. L. 1 Address �� w• � � Phone t. Contract r Addiessnl �b lCPhone� License No�3 ZZ�P —5T0 TYPE OF WELL/PUMP: NEW WELL—q— " WELL-REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION_❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK StLINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA a, CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t .. r"1 Public ❑ Other n Delta .. 'Depth'of Grout Seal Type of Grout I I Irrigation �.-Approx. Depth I I Eastern Surface Seal-Installed by _ Repair Work Done ❑ Type of Pump H.P. �! State Work Done_ Well Destruction ❑ Well Diameter Sealing.Material (top.501 17 Y Depthr Material (Below 50'1 1A —_ 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAI DDITION DESTRUCTION I I (No septic system permitted if public sewer is ice/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: er Numbof rooms ` v f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg --Gapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lin `� Total length/size FILTER BED 0 Distance to nearest: Wellso,� Foundation Property Line 1:57— SEEPAGE PITS I I Depth-~ Size kC2& Number r r L if SUMPS Distance to nearest: Wel!�! Foundation 00 Property Line DISPOSAL PONDS ❑ 1 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 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 c I for all r red spections. Complete drawing on reverse Fi Signed X Title: _ a Date d 0 I ;--� FOR DEP ENT USE ONLY 2 Application Accepted by Date 4 Area •Pit or Grout Inspection by Date Final Inspection b 'V 1� Date-2=�� C)--• Additional Comments: ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑FfVlar teca^823-9104 ❑Tracy.' 835=6385 �r r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-R.O. Box-2009, Stk.,-CA 95201 - 1FEE AMOUNT DUE AMOUNT REMITTED GASH CK RECEIVED BY DATE PERMIT'NO. FO +-EH 13-241REV.tical `/ EH 1428 1 c'7 d 1