SU0004477 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT tr[ � SAN JOAQUIN LOCAL HEALTH DISTRI 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 OPV, 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulation of the San J In Local Health District. Job Address -) .3 City Lot Size PM Owner's Name � Address 3 �� ZL4 — Phone Contractor r1 Address - 3 f'5- y TYPE OF WELL/PUMP: License No. Phone•1 NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONCl ❑, SYSTEM REPAIR L1 DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION INTENDED USE AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C}Domestic/Private ❑ G?avel Pack Dia. of Well Casing El Tracy Type of Casing ❑ Public ElOfher El Delta SpecificationsDepth of Grout Seal El Irrigation of Grout Irrigation —JApprox. Dep C) Eastern Surface Seal Installed by Repair Work Done Z Tykof Pump,—,d"-.4.— H.P. _ Well Destruction ❑ Welf;Diameter — State Work Done Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system available within 200 perm feet.) if public sewer is Installation will serve: Residence Commercial_ .Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg 1 Vater table depth PKG. TREATMENT PLT. ❑ Capacity— Nb. Compartments Method of Disposal e Distance to nearest: Well Foundation Property'Line _ 7 'LEACHING LINE ❑ No. & Length of lines R Total length/size. .. FRTER BED ❑ Distance to nearest: Well Foundation property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation i DISPOSAL PONDS ❑ Property Line 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, !shall not certifies the person in such manner as to become subject to workman's compensation laws of California."Contractor s hiring or suf�conissue , signature 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 appli mu call for al squired inspections. Complete drawing n reverse side. Signed ��° �rLt� yv, s..1; .,' rtle: ,� Date. I R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Ins . � pection by Date�� c Additional Comments: F ❑ Stk 466-6781 ❑ Lodi 369-362IJ Manteca 823-7104 ❑ Tracy 8355-63$5 Applicant- Return all copies to: Environ Intal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95MI I FEE AMFT DUE ( AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO.EH 13-24 iREV.t/esl leaia2a