SU0007221 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Rules and Regulations of the San Joaquin Local Health District. \ / Job Address 1-77e Q X I ae Q r y�Qt/� ') CXZ(F EN Tt.SLot Size / PM Ownees Name Mir< F: !)/4V I5 Address �C�Al . / Phone C frraacorMi)4/ VAA7C11 N yz Address %.:L O wlAf4C Jt ' License No. ,- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irtigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. tate Work Done .4J. Well Destruction ❑ Well Diameter Searing Material Itop 50'I 95*01 Ad VNVF_ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted H public sewer is J available within 200 feet) Installation will serve: Residence_ Commercial_ Other O Number of living units: Number of bedrooms O 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Properly 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant t call r all inspections. Complete drawing on r ver e. �i�,,c 1v Signed X � , </ -> Title: ! ^� Date: FOR DEP TMENT USE ONLY Application Accepted by /�-/ Date Area Pit or Grout Inspection by Date Final Inspection byate Additional Comments: 20 ❑ Stk 466-6781 ❑ Lodi 362-3621 ❑ Manteca 873-7104 ❑ Tracy 8356386 Applicant - Return all copies to: Environmental Health Permit/Services 1607 E. Hazelton Ave., P.O. Box 71109, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CEIVED BY REDATE PERMIT'NO. . EH 13-2C MEN T p EH ;425 \