SU0004854 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone_ (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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 M 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 I Local Health District. Job Address City Lot Size PM Owner's Name 's Address Phone i f t ^ Contractor Address License No., Phone /Lf, Fiti TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPACK ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other F Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by M Repair Work Done ❑ Type of Pump H.P. State Work Done F Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.V REPAIR/ADDITION l I DESTRUCTION I k (No septic system permitted if public sewer is { available within 200 feet.) f Installation will serve: Residence-1--- Commercial_ Other Number of living units: ___L Number of bedrooms 3 F7, Character of soil to a depth of 3 feet: Water table depth i, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well D Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total lengthlsize 17 4Va.D FILTER BED ❑ Distance gt�o nearel st: Well Foundation i D Property Line SEEPAGE PITS 11 Depth y Size Number SUMPS Ll Distance to nearest: Wellf h`a Foundation 1. 19 ti Property Line p 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, state laws, and` I 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."Contractor's hiring or sub-contracting signature i 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 t c or emu ired n pection mplete drawing on reverse side. Signed X E't�` Title: ea7a Data: _�6*,l FOR DEPARTMENT USE ONLY FApplication' �jAccepted by Date � Area fJt or Grout Inspection by Data -f. Fna! Inspection by C 9Date 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. F,. r' C r EH 13-24MEV.ti rt 5] + �� 01EH 114.26