SU0004333 - Laserfiche WebLink

Home Browse Search

'* / APPLICATION FOR PERMIT \.`, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. p Job Address � (.7[1 J (I City Lot Size PM Owner's Name wil-SeA) - Address Phone Contractor 1.4, G411_ Address �Ut 1 A4,4,tu 90C-4License No.2A:r� 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 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing - Specifications ('I Public ❑ Other Fl Delta Depth of Grout Seal" Type of Grout_ I I Irrigation —Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 G TYPE OF SEPTIC WORK: NEW INSTALLATION y REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ OlheP , Number of living units: + Number of bedrooms— Character of soil to a depth of 3 feet: ILD � v Water table depth SEPTIC TANK - ❑ Type/Mfg >�1- CapacitylGO No. Compartments PKG. TREATMENT PLT. ❑ - _ F; T' Method of Disposal f Distance to nearest: Well Foundation Property Line Total len th/size �r LEACHING LINE No. & Lengih of lines — 9 - F-r F� Property Line FILTER BED ❑ Distance to nearest: Well Foundatipn �L7 SEEPAGE PITS 74 Depth 1'h�-Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the worY,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." Contractors 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 call for all reg /yired I-nwections. plate drawing on reverse side. Signed X //� ff-t� Title: T Date: �. FOR DEPARTMENT USE ONLY Application Accepted by __. J Date / I Area D Pit or Grout Inspection by Date /–L Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE - AMOUNTDUE AMOUNT REMITTED CASH—RECEIVED BY DATE PERMIT'NO. INFO �l25 �4-15 . EH 14 (RE V.r/x51 N-A .Q EH Qe