SU0002527 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT 1..i SAN JOAQUIN LOCAL HEALTH DISTRICT 49I� jv 1601 E. HAZELTON AVE., STOCKTON, CA Bel is Telephone (209) 466-6781 1)1-ZC PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) SA(,�N��JOA//� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woAF4,L;r"s(f�'bCdr�ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatip s an Joaquin Local Health Disstrriiicct.( � Job Address /`" `/ [City(\� 1� -VLot Size PM Owner's Name f �� J�lIQC[L l,glq(ess �`+'d VW�1�I.I.I1 �C� Phone Contractor's Name / N" se No. /10 Z 3 73 Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'Ind—,.trial— ❑ 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 ❑ Irrigation ---Approx. Depth ❑ Eastern( Surface Seal Installed by Repair Work Done ❑ Type of Pump_AP e�T�IH.P. State Work Done Le ef��i1J r S>J PF Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ evailaeptic sy tem perfretted if public sewer isle _ 1 Installation will serve: Residence— Commercial_ Other V� 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 -a Distance to nearest: Well Foundation__ Property Line y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 certifies the following:" e ' that int rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californ' .' The applicant m f ireec specti . omplete drawing on revers e. Signed v Title: O Date: FOR DEPARTMENT USE ONLY J --�—�"s7 Date / � Area / ? Application Accepted bY//V Pit or Grout Inspection by N Dae Final Inspection bye Date Additional Comments: ❑ Stk 4664981 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 8355-6385 Applicant - Return all copies to: Environmental e h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEFr��DCASH CK RECEIVED By DATE PERMIT'N0. INFO 1� p 1 1 i EH 13-N♦IREy.10/®1 L. o EH t4ffi 1