SU0006597_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 thpwork t1prein described. This application is made in compliance with San Joaquin County Or ce No.549 f r �a or No. 1862 or weEl/ u and tt�e Rules nd Regulations of the San Joaquin i Local Health District. '/7 FIy - Job Addressi City Lot Size PM E Z113 Owner's Names)&Io Address Phone F ♦ r 6 Gontractor Address License No. S<3 , f% Phone 7 '62 TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` Ft; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK E ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB AREA' CONSTRUCTION SPECIFICATIONS �£ QIndustrial ElOpen Bottom 11 M nt a Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ racy Type of Casing Specifications ll Public Cl Other Delta Depth of Grout Seal Type of Grout _ I Irrigation _Approx. Depth //Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump Ai H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50') i Depth Filter Material (Below 50'I _ ` TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION l I DESTRUCTION I l Mo septic system permitted if public sewer is available within 200 feet.) Fi Installation will serve: Residence____ Commercial— Other Number of living units: Number of bedro f / Character of soil to a depth of 3 feet: e"dWater table depth f SEPTIC TANK ❑ Type/Mfg Cap ity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal 7 Distance to nearest:. Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ti Property Line SEEPAGE PITS I 1 Depth � Size e 1 r SUMPS Ll Distance to neatest: Well oundatibn Property Line DISPOSAL PONDS ❑ -,40K r f 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. 111 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 F 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. J The applicant ust call f r�N-required i spections. Complete drawing on reverse side. Signed X Title: Date: ; bo FOR DEPARTMENT USE ONLY Application'Accepted by Dace IduArea j Pit or Grout Inspection b Date Final Inspection by ✓` Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AAMRElM' CASH /RECEIVED BY D/A/TE PEE}RMIIT']N,O. 'w EH t924[REV.�iH51 no `:: , DUE VA �AMOUNT illV�REMITTED %(l p L/ EH 74-2e v !!"cc h/ h`�ILLsss V