SU0003474 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 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 Ryles and Regulations of the San Joaquin Local Health District. !J Job Address -) d_�l,2 11 Ci U — ty__ t Size PM Owner's Name � Address jh, ��[[ Phone3-6,,,r-- Contractor __�. Z Address 11_-_ _ rlcense No. ✓ ' Phone TYPE OF WELL/PUMP: EW WELL Ll WELL REPLACEMENT F, DESTRUCTION ❑ PUMP INSTALLATION f?' SYSTEM REPAIR G OTHER C 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 CJ Open Bottom 1-1 Manteca Dia. of Well Excavation Dia. of Well Casing C-ell�omestic/Private h Gravel Pack Ci Tracy Type of Casing _ Specifications f-1 Public E Other CI Delta Depth of Grout Seal Type of Grout___ Irrigation Approx. Dep L Eastern Surface Seal Installed by Repair Work Done P5- Type of Pump= H.P. /0 State Work Done Well Destruction LL Well Diameter _ Sealing Material {top 501) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 1-1 DESTRUCTION L. (No septic system permitted if public sewer is N available within 200 feet.) [ 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. LI Method of Disposal Distance to nearest: Well __ Foundation Property Line LEACHING LINE L No. & Length of fines Total length/size — FILTER BED f ! Distance to nearest: Well ___ Foundation Property Line _ SEEPAGE PITS i.J Depth __Size . Number SUMPS Ll Distance to nearest: Well Foundation _ Property Line _ DISPOSAL PONDS L 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 shalf 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." The applicant Ist ca for all re d inspections Complete drawing on reverse side. 4i Signed X_ �! 1e: jr} Date; �0 , FOR DEPARTMENT USE ONLY / I ! / C� Application Accepted by Date i Areael Pit or Grout Inspection by Date Final Inspection by Q � Date Additional Comments: 0 Stk 466-6781 Ll Lodi 369-3621 El Manteca 623-7104 LJ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH EH 13-24 + EH 14-26 IftEV. 4� /--�"A