SU0004532 SSNL - Laserfiche WebLink

Home Browse Search

n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1'YEAR 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 weH/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 24-717 95, Z544dID17City. Vr!rLot size A PM r- M1 Owner's Name -0-01. CAddress _W 6ax_ �7 te. C,4n�,s' Phone ! Contractor Q6 Address � License No. ��S'7-7 fa Phone -39 7/ TYPE OF WELL/PUMP: NEW WELL C WELL RLPLACEMFNT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] 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 ❑ Industria! ❑ Open Bottom E2 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack C] Tracy Type of Casing Specifications FI Public Other FI Delta Depth of Grout Seal` 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 ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDI I1UN l ] DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.i Installation will serve: -Residence— Commercial?� Other Number of living units: Number of bedrooms Character of soil to a depth of 3'feet: C LAY Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 2490 No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: .Well-AeW 147 J Pro tart Line �/ Foundation p y �pQ LEACHING LINE L*I No. & Length of lines _ Z -46", Total length/size 96, FILTER BED - ❑ Distance to nearest:- Well Foundation��_ Property Line -C49 _ SEEPAGE PITS Id Depth ,f cv _Size ��.. .— Number .SUMPS L"I" Distance to nearest: Well ,020"lir Foundation 1490„ Property Line S�? ___ i DISPOSAL PONDS ❑ / k 12, K 1Z S u m p 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 I 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." i The applicant must call for all required inspections. Complete drawing on reverse side. i Signed 4&V-WTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area IP' or Grout Inspection by Date , 3 Final Inspection by (Additional Comments: .";, � FFF ❑ Stk. 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 823-7104 ❑ Tracy' 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_, P.O. Box 2009, Stk., CA 95201 EE IN AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PEAMIT AEO. +.EH13-24(REV.liks! U� �t .