SU0004279 SSNL - Laserfiche WebLink

Home Browse Search

FjAPPLICATION FOR PERMIT 64 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JABS I Z 11-bd PERMIT EXPIRES 1 YEAR FROM DATE ISSUED hEti�f Fl (Complete in Triplicate) SE- L' WCES 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. Lot Size PM Fi Job Address77 Owner'sName 1`0 Address d/YV�'�-� _ Phone 14 1 F Contracto �!�� Address t? License No.10_30617` Phonesg" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ F PUMP INSTALLATION Lel SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 1 _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! I ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i-1 Public 1711 Other ❑ Delta Depth of Grout Seal Type of Grout a 1 1 Irrigation —Approx. Depth E I Eastern Surface Seal Installed by Repair Work Done Type of Pump H. ��'`"�� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation 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 Capacity No_ Compartments Fi PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Welt f=oundation Property Line, PLEACHING LINE Ll No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number / SUMPS LI to nearest: Well Foundation Property Line 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 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."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,1 shalt employ persons subject to workman's compensa- tion laws of California." ! The applicant mu all for all requi d inspections. Complete drawing on reverse side. Si ne Title-12a_,t - Date: ! 9 On PARTMENT USE ONLY ` 444 Application Accepted by Date f Area `� `-' Pit or Grout Inspection by Date Final Inspection by Date J Additional Comments: ❑ Stk 466-6781 O Lodi 368-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH (� Q } FH 4 1REV.1/H 51 EH 14-2 r'