SU0007122 - 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) y 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 incompliance 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. it / Job Address /on N�YT J City 49 Lot Size CS �Ci2 PM I ` Owner's Name f� M Address an Phone Contractor's Name SA-1-1105 License Phone TYPE OF WELL/PUMP: NEW WELL ❑ (WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWERI'LINES DISPOSAL FLD. PROP. LINE I 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing Specifications 0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 ❑ Irrigation ---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 501 Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 13 DESTRUCTION 13 (No septic system permitted if public sewer is I available within 200 feet.) t Installation will serve: Residence_ Commercial 4 Other - ----Number-of-livingi,lnits: _ ---- -Number-of bedrooms Character of soil to a depth of 3 feet: Water table depthTM SEPTIC TANK Type/Mfg v- No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well a' Foundation Property Line r. e� 1 LEACHING LINE No. & Length of lines oC " - Total length/size FILTER BED.. ❑ Distance to nearest: Well Foundation Property Line j 1 SEEPAGE PITS © Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 'k DISPOSAL PONDS ❑ �.. 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: "J 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."Contractoes hiring or sub-contracting signature certifies the fol! "I certify that in th performance of the work'for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws p alifornia.' The app)' a mu II for all r dins ions. Complete drawing on reverse side. l Signed Title: �� 1�~ ,�/�� Date: —0k r FOR DEPARTMENT USE ONLY � A: 1 Application Accepted by 1�'//`�i Date � � L� Area f Pit or Grout inspection by Date Final Inspection by sr' Date 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, Stk., CA 95201 FEE- INFO AMOUNT DUE AMOUNT REMITTED;; CASH RECEIVED BY DATE PERMIT•`N0. .fi +EN 3-24 EH 1426(REV.10!83) 4 ii