SU0002816 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 5--� 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. Job Address_ �'.3 � C. +'iL'� ' Q�r Subdivision Name Owner's Name N 1 'A 'k D Address Phone Contractor's Name [- .L License No. Phone4.7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE__OFZWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C ❑ Industrial U Open Bottom E]Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public [j Other ❑Delta Type of Casing Irrigation Approx. Eastern ❑Cathodic Protection � Depth ❑ Specifications Depth of Grout Seal ❑Geophysical Type of Grout 11 Other Surface Seal Instal]ed by Repair Work Done ❑ Type of Pump H.P. State Work Done P Well Destruction E] Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADi31TION (No septic tank or seepage.p t.permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size;_21,e }( /P Character of soil to a depth of 3 feet: — Water� � ___ Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE XJ_' No. & Length of lines -- ,+ 7 '7— Total length/size i'7- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state haws,-and rules and regulations of the 'San Joaquin Local Health District. Nome 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." t 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 compensation laws of California." The 'applicant must�call f , a equired inspections. Complete drawing on reverse side. / Signed X ( Title: tt etc Date: ' / YL 1 0 ARTMENT USE ONLY Application Accepted by Area _ _ ❑ Stk. 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by: Date ❑ Manteca 823-7104 Final Inspection by •�/i!� .. Date ❑_ Tracy ' 835-6385.: Applicant - Return all copies to: . Environmenta Health Perm t/services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT 'Dtlt AMOUNT REMITTED RECEIVED BY DATE PERMIT;NO. INFO . EH 13-24 REV. 10/82 10/82 500 14-26