SU0006750 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 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. PA Job Address City Lot Size • PM Owners Name 6. Address Phone r Contractor Address f a, V ��yy - License Nd.- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 5 Open Bottom ❑ Manteca Dia. of Well Ezwvation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealW ElIrri Irrigation -_Type of Grout 9 ---Approx. ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 p� 6eptF Fill r Material IBelow 50') C" TYPE OF SEPTIC WOF K: NEW INSTALLATION - REPA R/ADDITION DESTRUCTION ❑ (No septic system permitted H public se r.is t// available within 2g0 feet.) Installation will serve: Residence_ Commercial Other r Number of living units:� Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth T - �f SEPTIC TANK >�ype/Mfg _ d ac raj No. Compartments �/+ PKG. TREATMENT PLT. ❑ 1 t Method of Disposal Distance to nearest: Well 5b Foundation 1�_ Pro party Line LEACHING LINE X No. & Length of lines Total length/size .n t FILTER BED ❑ Distance to nearest: Well �� re�/ t .�"¢_L_ Foundation LO 7 -� Property Lina�� SEEPAGE PITS - ❑ Depth Size Number A r SUMPS d Distance to nearest: Well Foundation Property Line {� DISPOSAL PONDS ❑ 1�1� I hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin county ordinances, rules and regulations of the San Joaquin Local Health District. state laws, and r 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 subcontracting 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." r The applicant must call for a requir specti ns. Complete drawing on revers side. i I � Signed Title: Date: { FOR DEPARTMENT USE ONLY Application Accepted b4bV I + - - �j�+ �? L. n _ Date Area Pit or Grout Inspection IllDate - Final Inspection by DaterAdditional Comments: r7�'.i eifi '49r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.638.5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE PERMIT`NO. A - .EH IC1419 /( `