90-151 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT f1IL SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Joa u n Local Health District. Job Address ` r� RA - City LXk"T Lot Size �Q�+ PM Owner's Name t^�e,�tYZ S " A _ Address -" - Phone 2S5^ Contractor bfM CAS',e Address 5� &`p"v"' .Ave License No. 2L131) E3 Phone g27'_"'?Y— TYPE 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 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 ❑ Other ❑ Delta Depth of GrouSteal Type of Grout' I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 y Depth Filler Material'f Below 50'I _ �✓ TYPE OF SEPTIC WORK: I NEW INSTALLATION REPAIR/ADDITION (7.] DESTRUCTION i I (No septic system permitted if public sewer is ;available within 200 feet./ Installation will serve: 46'sidence I/ Commercial_ �ther I� Number of living units;. Number of bePorn. } U' Character of soil to a depth of 3 feet: iNO Water table depth 1 tao t I SEPTIC TANK ��'❑ 1 Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT.❑ ' ,4 f Method of Dis oral { j P Distance to nearest: Well ��F Foundation 3� Property Line- -'5--- LEACHING LINE ❑ No. & Length of lines Total length/sizi i O t FILTER BED ❑ Distance to neaeest: Well Foundation Property Line Cl SEEPAGE PITS I I Depth Size _ Number SUMPS Cl Distance to nearest: Wei[ 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 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." 1 The applicant must call for all required inspect' ns. Complete drawing on reverse side. I .� Signed 777_"V Title: r Date: �•- FOR DEPARTMENT USE ONLY i Application Accepted by I Date t w 7 d Ar Pit or Grout Inspection by Date Final lnspection by Date Additional Comments: ❑ 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.0' Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNTREMITTEDCK /RECEIVED BY DATE PERMIT NO. ♦.EH 13-24(REV.I/A5) D.� ri O � �f� VIS { '".;U_1— . 151 EH 14-215 1Y' V I V