SU0003999 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 — (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 / / f�L`�l4 :6942 �a Cit Lot Size �r e-- PM Owner's Name Address - Phone —V 7211LI Contractor V� - y Address t " License No.Via/ Phone6/ ` 3 ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE=STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other fl Delta Depth of Grout Seat Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ `J Repair Work pone 0 Type of Pump H.P. State Work Done _ t Well Destruction ❑ Well Diameter _ Sealing Material (top i .• Depth Filler Material (Below 501/ a TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of diving units: .— Number of bedrooms Character of soil to a depth of 3 feet: -Df}'m r ' Water table depth N, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal i Distance to nearest: Well Foundation Property Line 1 LEACHING LINE 5—No. & Length of lines l \Y6 { Totat'Ilength/size a FILTER BED ❑ Distance to nearest: Well�U� r Foundation AX Property Line -,2q) 1 - SEEPAGE PITS IL?�Depth 5 Sizo _ Number SUMPS Ll Distance to nearest: Well ,/ �' Fet;ndation 41 f Property Line lira DISPOSAL PONDS C1 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 owneror licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not' employ any person in such manner as to become subject to workroan-s cormpensatioh-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." Theapplicant must call f f all eguired.inspections. Complete drawing on averse side; i ' Signed X_ � � i Title: ffJ,alC�f j Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area it r Grout inspection by atee_t? Final Inspection by Date Additional Comments: 1 ❑ Stk 466 8781 -Lodi:_369-3621 - ❑ Manteca-823 7104--~-'"0°Tracy-835-6385' Applicant- Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton'Ave., PA. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE]] AMOyUNT REMITTED CASH CK 4 RECEIVED BY p DATE ! PERMIT'NNO.f * EH 14-26 IREV.1 i n 51 .r�r3 ,�.'�3 ' � U t n d / L f'12-