SU0006850 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAtidOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. //7 /J/r�J{�� _ - r Job Address • � ��/ r' r–"�/'� �r-- City Lot Size PM Owner's Name � '• pal Add Phone 3 Contractor's Name No. Phone "' /D 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 ❑ Dom4tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SPeci6catrom ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type tN Grout ❑ Irrigation --Approx. Depth ❑ 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 Fillet Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAID/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted If Public sewer is ✓/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 Number of living units: _ Number of bedroopts /,-� Water table depth Character of soil to a depth of 3 feet: {b1i��//—�7� SEPTIC TANK ❑ Type/Mfg I Capacity� No. Compartments PKG. TREATMENT PLT. ❑ Method of D' I Distance to nearest: well r7 Foundation Property Lins� LEACHING LINE ❑ No. 6 Length of livres �- L' Total length/=,- --FILTER BED ❑ Distance to nearest: Well dation Property Line SEEPAGE PITS ❑ Depth f Ize Number M ❑ Distance to nearest: Well Foundation Property Line D19'POSAL PONDS ❑ 1 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."Contractoes 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." �^�E The applicant m s I all,,rrj�1uii'Nr'/'�/_rrJ'�y[[)('sm'"//!,'tions. Comple drawing on r nae side. Signed X ;?r,6 _"/^� Title: ��'y "'X– Date: 9 FO PARTMENT USE ONLY o Date �0�46 Area Application Accept by Pit or Grout Inspect Date/ Z 6:�,& Final Inspection by Date Additional Comments: ❑ Stk 4666791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835MM Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96MI FEEF-7! UNT DUE AMOUNT REMITTED CASH RECEIVED eY DATE PERMIT NO. INFO . EN 1}N IREV. 101831 EH=