SU0004638 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA uL Telephone (209) 466-6781 lJ _�--- 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. Job Address C/< 7_61 Al,—"-- City Lot Size !C",040 PM Owner's Name CW K-4,1/✓ �!7-V/51- 64 U Address _ :.r 191610X5 Phone 91Y6" Contractor's Name ��'iP/,JH / S�N�' License No. -2 3-!5o/— -79Y,7 Phone E fJ 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 r. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial CTO n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ITI ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout IN El Irrigation -.0 Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 71REPAIR/ADDITION DESTRUCTION C3 (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence_V�_ Commerciel_ Other Number of Irving units: _Z— Number of bedrooms.— Character of soil to a depth of 3 feet: G, 9 Y Water table depth Lt , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t� PKG. TREATMENT PLT. ❑ Method of Disposal / Distance to nearest: Well Foundation Property Line \N r / LEACHING LINE No. & Length of lines �/ — �/D Total length/size / FILTER BED ❑ Distance to nearest: Wail--,5'-6 / Foundation 0 D Property Line SEEPAGE PITS Depth �.S'r Size 4fE Number _f SUMPS ❑ Distance to nearest: Well. /ViO ' Foundation 2_J v 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: "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." Theapplica tcall for all required in echo s. Complete drawing on re�versq Aide. Signed Xi Title: Date: - `/+ FOR DEPARTMENT USE ONLY Application Accepted by ` `3 _ Pit or Grout Inspection by '�� Date le k`/ Final Inspection by /� Date VAd tonal Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE �. INFO AMOUNT DUE AMOUNT REMITTED CCK# RECEIVED BY DATE PERMIT-NO. EH 13-24(REV.to/adl S '3�1 b/ 4 gLi-Z77 EH 11ffi 1 e o