91-0046 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,' STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES TYEAR FROM DATE ISSUED �I (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 II ter" "v _ City Lot Size PM Owner's Name S741Address ,T _ Phone FE3 V,3 2l ffim�S_Addresspio&Contractor / �.� f L] License No. J�L3 75 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION !I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I� TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS I` ❑� Industrial li ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 17YDomestic/PrivateI ravel Pack ❑ Tracy Type of Casing Vim- Specifications f I Public II ❑ ther (�a Depth of Grout Seal 100 Type of Grout ` _ € I Irrigation II l4Approx. Depth I I Eastern Surface Seal Installed by " 4 Repair Work Done +❑ Type of Pump H.P. L State Work Done_ r —/ b Well Destruction I Well Diameter Sealing Material Itop 50') .:Il • Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RI;'AIR)ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is 1 1 1 available within 200 feet.) Tl i Installation will serve: Residence— Commercial_ Other Number of living udnits: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK !� ❑ Type/Mfg Capacity . No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length'of lines Total length/size FILTER BED .i ❑ Distance to nearest: Well Foundation Property Line G SEEPAGE PITS II I I Depth Size _ Number SUMPS r 0 Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS I, ❑ 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 certif the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor The applicant stcaor a inspections. Complete drawing on r arse side i /r5igned Title: ` �" ^Com`'L ��+� v Date: II FO EPARTMENT USE ONLY ` Application Accepted by Date ^p ` Area 1 (0 q Pit o Grou Inspection b Darr/ Final Inspection by Date �� 9 oi- ` Additional Comment's: ❑ Stk 466-6781 1i ❑ Lodi 369-3621 ❑ Manteca 823-71A—Af ❑ Trac 835-6385 "�� ` ?P3.,-Ie<_ Applicant - Return all copies to: E vironmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009 Stk., CA 5201 CA war C&_ d FEE ! INFOI' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE+ PERMIT N0. +.EH13-24(REV. /M51 1 W - � Qlr.� ! EH 14-28 1! 1