90-1122 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Of=F -4f (y I Job Address �y�`I �/U�'�7' _LAT`-�_ . _ City SJ Owner's Size PM Owner's Name Address i1b gox al e ci -,sT1zN Phone qV t m F Contractors&G m !N Ass license N,.,5 � O Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)< 2 7-6&3` J3pYt1 I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE [ 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _5pesi#ieatierj j f'1 Public 1-1 Other 71 Delta Depth of Grout Seal kf i I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed bys_ l Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 'bnLCE 119"Lils 11 /r— I Depth Filler Material (Below 501) 6W �1�+CC3Ll .tri 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION Ll DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) S Installation will serve: Residence_ Commercial_ Other C? i Number of living units: Number of bedrooms + Character of soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS CI Distance to nearest: Well 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 D11trict. r 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 st call for l"►eR fired inspections. Complete drawing on reverse side. [[�� p Signed Xs� Title: � lS� Date: —_'7— ..- FO DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date [S SqwsLL PrptAdditional Comments: _Dr, ) qtr., J U"6 . fZ /� 1 ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 83 -6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED K Z7MH RECEIVED BY DATE PERMIT NO. r-EH 13-24(REV.I/KS) � f.� S EH 19-2e `t tO } O d"'1�1-2-