SU0003662 - Laserfiche WebLink

Home Browse Search

. .'�APPLICATION FOR PERMIT k ° SAN JOAQUIN LOCAL HEALTH DISTRICT d 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 COP PERMIT EXPIRES 1"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. �,C�e� Job Address x City (�}} Lot Size Pm �.N\ Owner's Name ' QL AddressiV 1�Q ��j&-, T�y� Phone Contract Addresso e License No. Q Z z�o Phane`��'' /�'S 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 PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑'Dorhestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout -_- I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Typlg of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50'1 ' Depth 'ller Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION [.I AEPAI ADDITION DESTRUCTION I I (No septic syslem permitted it public sewer is.. available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: (-9 Number f edro s 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 LEACHING LINE ❑ No. & Length of"lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f tl SEEPAGE PITS Ky Depth Size_ _ Number SUMPS Cl Distance to DISPOSAL PONDS Ll nearest: We 0 Foundation Property Line `."_,__ '�" I hereby certify that I have prepared this application and that the wovk.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: "I certify'that in the performance of the work for which this permit is issued, I shall employ persons subjectlo workman's compensa- tion laws of California." The applicant must c for all.rbq it i ctions. Complete drawing on reverseysi 'e. Signed X Title: l r Date: 1rOR DEPA MENT USE ONLY Application Accepted by Date` Area G� � f Pit r Grout Inspection by Date Final Inspection byate. 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, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO. 1324(REV.I/x 5) 14-28