SU0007237 SSNL - Laserfiche WebLink

Home Browse Search

SUNAPPLICATION FOR PERMIT _9 ,++ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 .&813 c3 /V1 NOCAuJ',;, 4/Q.de A City L AZ Lot Size AC PM /J r owner's Name C7 at r B O M!eA 11 cl ess Phone 3( ^ Contractor cV4( Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME DESTRUCTION ❑ 6. PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ ... DISTANCE TO NEAREST: SEPTIC TANK SEWER NES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT W L OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PROB;AREA C - RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom- - - ❑Maia.-of -Excavation Dia. of Well C_sing ❑ Domestic/Private ❑ Gravel Pack ❑ TraType of Casin Specifications ❑ Public ❑ Other ❑ DelDepth of Grout al Type of Grout ❑ Irrigation �Approx. Depth ❑ EasSurface Seal Installed by d� Repair Work Done ❑ Type of Pump H.P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') V\3 Depth - Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial Other t Number of living units:_ Number of bedrooms—3_ Character of soil to a depth of 3 feet: .^. Water table depth SEPTIC TANK (Type/Mfg _ Capacity�o No. Compartments (o r PKG. TREATMENT PLT. ❑ Method of Disposal F Distance to nearest: Well SQ_ Foundation 10 Property Line 3O LEACHING LINE B�No. & Length of lines Tgtal length/size FILTER BED 11 Distance to nearest: Well� Foundation i�R_ Property Line C9 00 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property 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." Contractors 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 m s all for all q 'ed inspections. Complete drawing on reverse side. Signed Title:Cr a/V1,t � Date: FOk DEPAMXMENT USE ONLY Application Accep by Date '—�� Area 0 Pit or Grout Inspection by -- --Bata Final Inspection b �'' q," Datela Additional Comments: ,� 1161 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ 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 NO. ♦ EH 1324 IREV.I Is 70, EHrd-