SR0079804 - 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 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 Coonty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. // 4 -7 dl��J -`f .rr' .. CitA__# / Lot Siz �— 1 PM Job Address 4 Owner's Name 1` Address ( �1 ' /V,. & e Phone Contract r*.-- r<a k Address��', � � License No. zZ Cl Phone. o +/� TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;! T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications FI Public M Other ❑ Delta Depth of Grout Seal ��.r 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 7 Welt Diameter Sealing Material it6p 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION ( I' DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation wrli serve: Residence—V� Commercial_ Other I Number of living units: —�— Number of rooms Character of soil to a depth of 3 feet: j�1�* Water table depth SEPTIC TANK Type/Mfg f 9�L�',2 Capacity�r_r c lc No. Compartments PKG. TREATMENT PLT. ❑ ' g ti t� Method of Disposal JD Distance to nearest Well !.7undation 40 Property Line - 15, LEACHING LINE No. & Length of lines HO — r� Total length/size FILTER BED ❑ Distance to nearest: Well� Foundation l G Property Line C SEEPAGE PITS `� Depth q9 15 Site r Number y t' SUMPS Ll,_ Distpnlgo to,nearest: Well ` _Foundation tit') Property Line DISPOSAL PONDS ❑ Ut 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, an 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 nov employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatttrer certifies the following: "I cartify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa tion laws of California." The applicant m call for all r ' ed i spections. Complete dr'awing on reverse si Q�] Signed X Title: � Date: - A FO F DEPARTMENT USE ONLY / � _ r Application Accepted by�r _ Date �.�C�!.._ Area or Grout Inspection by ...Data�r ' '� FinalAnspection by 4e, Date Z- ff Additional Comments: Y `' ❑ 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.O. Bax 2009, Stk:, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �7 CASH [� •.EH 13-241REV,i1K5) - /0 EH 14.20 / 1