SU0006409 SSCRPT - Laserfiche WebLink

Home Browse Search

d n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ! (Complete in Triplicate) I 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 wA San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin R Local Health District. Job Address �' City ' Lot Size PM I Owner's Name '_ Address Lo ✓• – Phone, AO RP Contract G�4� `rA Address License No �J_Z 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 r INTENDED USE T'0E 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 ❑ 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 S41ing Material {top 501 Depth )ler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I I .REPAI ADDITION i DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will servo: Residence Commercial _ _ Other Number of living units: ___ Number of be/rooms Character of soil to a depth of 3 feet: Water,table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments FPKG:TREATMENT PLT.❑ r Method of Disposal r Distance to nearest: Well Foundation Property.Line LEACHING LINE No- & Length of lines Total length/size X / � FILTER BED ❑ Distance to nearest: Well�� Foundation 40 Property Line I r� SEEPAGE PITS Depth Sire Number _ �d SUMPS ❑ Distance to nearest: Well Qz Foundation 49 Property Line ttt - 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, slate 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." F The applicant mu I for to ir -nspections. Complete drawing on reverse 'd . iii Signed X Title:F A F Date: FOR EPARTMENT USE ONLY + Application Accepted by C DateI� Area 2— or Grout Inspection by ` Date U Final Inspection by � Date(_1 'td F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F! FEE�� INFO AMOUNT DUE AMOUNT RwiTTE) [CASH RECEIVED BY DATE f ERMI7'NO. ♦..EH 13-24(FIEV. /H51 -7� 04 14-26 a