SU0006963 - Laserfiche WebLink

Home Browse Search

E U z 4.oz' a� sir APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I-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. G Job Address/ f City Gt- Lot Size .fi Owner's Namelpl-� - (c C+� y. n(3 _ Address 33 1 �/�s�-�c� Phone — - U Fl Contractor pz-e� i Address License No.f(c 13 7-3�Phone �14— TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT �N DESTRUCTION Cia- PUMP INSTALLATION 5� SYSTEM REPAIR ❑ OTHER ❑ ? DISTANCE TO NEAREST: SEPTIC TANK ISO " SEWER LINES OC t DISPOSAL FLD. PROP, LINE Z bct FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialO Open Bottom ❑ Manteca Dia. of Well Excavation b (o rf Dia. of Well Casing *Domestic/Private K Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other n Delta Depth of Grout Seal ' Type of Grout I ! Irrigation Approx. Dept�Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona �i Well Destruction (R Well Diameter Sealing Material (top 50') * .x� rr .. Depth Sc Filler Material {Below 50'I- TYPE OF SEPTIC WORK: NEW INSTALLATION l;l REPAIRIADDITION I 1 DESTRUCTION 1.1 (No septic system permitted if public sewer is d available within 200.fe:et.) Installation will serve:. Residence--�_ Commercial— Other Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑' Method of Disposal Distance to nearest: Well Foundation Property.Line l LEACHING LINE ❑'i No. & Length of lines 'I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E): hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 u i cad or all r quir d inspectians. Complete drawing on reverse side. Signed X `title: 7 Date: j FOR DEPARTMENT USE ONLY (/� �� r r Ar lCY Applicati Accepted by ate €' 6:E& Pit nspection b Date F spection by Date i! Additional Comments: e, ❑ Stk 466-6781 L1Lodi 369-3621 C1Manteca 823-71 ❑ Tracy 835-6385 a ,trek-c� Applicant Return all copies to: Environm ntal yaalth Permit/ ervi s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED 8Y DATE PERMIT NO. +.EH 13-24{REV.I?x 51 EH 1428 Z --7/E4/ .• G^-111n