SU0005305 - Laserfiche WebLink

Home Browse Search

' T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA FIL E Telephone (209) 466-6781 Cap ! 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 �- 9J� L7e�'T,� Ufa; City TY% C Lot Size 47 YD'S -- PM Owner's Name _'1!�w"f L� ✓�c�l V _ Address _"lf Phone OF Contractor �H Address �� '00f k:;r1r_' f�r.� �� License No. Phone_ 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 INTENDED OSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 11:1Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L—Approx_;Depth ❑ Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work Done e Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth i Filler Material (Below 50.1 TYPE OF SEPTIC WORK: -.NEW.INSTALLATION F, REPAIR/ADDITION•O- °DESTRUCTION-f3'(No septic system permitted if public sewer is available within 200 feet.) Installation will serve:., Residence A Commercial Other f Number of living units:; Nurriber of be ooms Character of soil to-,a,depth of 3 feet:I Water table depth iSEPTIC TANK � Type/Mfg fir � Cr. mac• Capacity No. Compartments PKG. TREATMENT PLT_❑ i Method of Disposal Distance to nearest: Well Foundation Property Line i !LEACHING LINE `6M No. &Length of_Ii res '34' z Total length/size Yc` FILTER BED 11Distance to nearest: Wef Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation + Property Line DISPOSAL PONDS ❑ 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 Joaquirn 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." .The applicant.must ca I for all required pp eq inspections. Complete drawing on reverse side. , Signed Title: Date_ S-- FOR DEPARTMENT USE ONLY Application Accepted by Date if 7 Area �Q Pit or Grout Inspection by ftte Final Inspection by Date ;Additional Comments: '❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 3-24(REV.lin51 4-ZB �~ /0, /EH 1 O, �