SU0004532 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 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 Joaquin Local Health District. r^ w �--- Job Address ��o`� � � ` fin'�� City �d`� / Lat Size � [ ✓ ��PM f fl Owner's Name 06 rams Address C Phone � t Contractor Address License Noa Phone at 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 ` L ",. � ,;INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,1 fl`Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V� ..' 0.0omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �f 1-1 Public n Other ❑ Delta Depth of Grout Sea] p Type of Grout _. n 1 1 Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 t' 1 Depth Filler Material (Below 501 V TYPE OF SEPTIC WORK.: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) F� Installation will serve: Residence Commercial_ Other Number of living units: A____ Number of bedrooms_3 Character of soil to a dthh f 3 feet: Water table depth SEPTIC TANK ; Type/Mfg 66ACjl"' Capacity � No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 4- Foundation >f_� Property Line Q n f t� LEACHING LINE pr""No. & Length of lines t5 Total length/size Tv� FILTER BED ❑ Distance to nearest: Well 00 Foundation__ Property Line E ? SEEPAGE PITS Depth r 5 Size 3 I, Number SUMPS ❑ Distance to nearest: Well.!47n- Foundation_ � Property Line DISPOSAL PONDS 0 . 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."Contractors 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 must call for all required inspections. Complete drawing on reverse e side. Signed x Title: ii59 u� nate: 1��why _...... FOR DEPARTMENT USE ONLY r -7~ / Application Accepted by data c. r Area e-- ? F ' it r Grout Inspection by� Date inal Inspection by Date p� Additional Comments: i` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 'i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Fi FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r F'- I_ + EH 1324 IREV.1/1151 - �jL � �• � � C� . � � EH 1428