SU0006288 - Laserfiche WebLink

Home Browse Search

t 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTf 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Al City Lo 0/ Lot Size PM Owner's Name 2A,0,C f—fJ?l�st� Address I Phone . r'Z Contract Address License No. Phone TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS D. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS -• ❑ Industrial O Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F'1 Public n Othe 171Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth t 1 Eastern Surface Seal Installed by Repair Work Do Type of Pump N.P. State Work Done _ Well D ctipn CO3 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t.1 REPAIR/ADDITION t I DESTRUCTION No septic system permitted if public sewer is 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 f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1. Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 1 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 Di1trict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X� �_�- �~--�� Title:_t) "3 — Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area , Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 L7 Lodi 369-3621 0 Manteca 823-7104 ❑ 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 RUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT-NO. INFO EH 13-24 Iitev.1/li w tog ai EH W26 \5•./O - tP