90-321 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA TVptLta%i� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �]��t� (Complete in Triplicate) 'Np °''°jA*,, 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. r ,: gV'r Job Address .1a City Lot Size PM I Owner's Name f �� /lfddre { t f = Phone - � Contractor ! Address -'. License No. Phone TYPE OF WELL/PUMP: NEW WELL>Ld WELL REPLACEMENT ❑ DESTRUCTION ❑ T.:.:.. PUMP INSTALLATIOAI C':1°':`:".` SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout I t Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by r _ Repair Work Dont: ❑ Type of Pump H.P. State Work Done Well Destruction (D Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_� Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth ' SEPTIC TANK ❑ Type/Mfg1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. eat Length of lines Total length/size FILTER BED ❑ Distance trir nearest: Well Foundation Property Line SEEPAGE PITS l I Depth i Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Joaquini Local Health Di§trict. 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." Contractors 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 must call for all requires ispections. Complete drawing on reverse side. Signed Lam" Title: �`Z -� - _.. Date: F R DEPARTMENT USE ONLY ` Application Accepted by _4". Date l7 Area r Pit or Grout Inspection by Date Final Inspection by Date / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE ! AMOUNT REMITTED CASH Jc RECEIVED BY DATE PERMIT'NO. + EH 3-24(REV � 'O `"rte 1�� /�� 16P-rte ^ EH 112e ��yJ J ��C/1