SU0008383 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQl11N LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 ..,`� w: `-- --'• T . `r ?" PERMIT EXPIRES 'IYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fors permit to construct andlor insw,-the work herein tlestribad. 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. -�T Job Address Lot Siie ` PM Owner's Name _ !_ Address ��'�phone F Contractor + �-_ Address License No- Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1i PUMP INSTALLATION O SYSTEM REPAIR.0 OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -'PITS/SUMPS s f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^^^ ❑ Industrial LJ Open Bottom ❑'ltdanteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F f-I Public n Other F Delta Depth of Grout Seal Type of Grout I I Irrigation —Approa. Depth I 1 Eastern Surface Seal Installed by , Repair Work Done ❑ Type of Pump H.P. r State Wprk Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 /] rX�+ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIRIADDITION 1.1 DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.) tnstallaWn will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg - CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal F , Distance to nearest: Well Foundation Property.Uns LEACHING LINE 0 No. & Length of lines t ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation- Property Line f SEEPAGE PITS I f Depth Si:e, Number SUMPS ❑ Distance to nearest: Well. -• foundation Property Line DISPOSAL PONDS ❑ •r' i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,slate laws, and rules and regulations of the San Joaquin Local Health District,, t Home owner or licensed agent's signature certifies the following: "I der4y that in the performance of the work for which this permit is issued, I shall not r a employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring 1 n9 or sub-contracting signature certifias 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 Calif r la.- The rlpplican It call or all q red inspections. Complete drawing on reverse side. Signed l Title: Date: `*1r'�`/`r f ! zpt r FOR DEPARTMENT USE ONLY Application Accepted by 1AZ - _ Date res t 3 Pit or Grout Inspection by Date Final Inspection b Owe Date Additional Comments: ❑ Stk 466-6781 O Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i ' INFO AMOUNT DUE AMOUNT REMITTED I CA5H RECEIVED BY 1 DATE ��PffE++#iM11fh,,T•INo. +.EH t}2�IREY.r r n aY 0 v DCa5 ' EH 11.28 I