SU0004313_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 9 YEAR FROM DATEASSUED (Complete in Triplicate) 6 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i ,fob Address /y3o f �� City lot Size PM r Owner's Name AddressPhone Contractor *,-vw Address _. . nse No 2 Phone / TYPE OF WELL/PUMP: NEW WELL 1J WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F." INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustnal ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing 4 j F1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ v I I Irrigation —.Approx. Depthi I I Eastern (Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump M.P. t�V Q� State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 11 !� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (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 dept SEPTIC TANK ❑ Type/Mfg Capacity, No. CgWait ryl I, PKG, TREATMENT PLT.❑ Meth isposal Distance to nearest:' Well Foundation Property Line LEACHING LINE ❑ . No- & Len th of lines 9 Total length/size FILTER BED O Distance to nearest: Welt Foundation Property LEIV NIMTAL HEALTH SEEPAGE PITS l I Depth Size _ Number F�' SUMPS Ll Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ j 1 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 I 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-contractingsignature 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- F, tion laws of California." r The applicant must 11 for�pllrequired - spections. Complete drawing on reverse side. Signed Title: Date: CSL " FORD ARTMENT USE ONLY Application Accepted by Date Area �1� 4 Pit or Grout Inspection by Dat© Final Inspection by `�– Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-665 I Applicant - Return all copies to: Environmental'.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE pERM17'NO. F. EH 14-M1 -7—xqIREV.I/n51tiEpi �� _ ♦ j -�^�� k � 14-2e -