SU0004396 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEASSUEb f ° (Complete in Triplicate) i 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. �L. it 1;` 74-PM, Job Address ,., City I.,ot Size. � Owner's Nam �' dress J1dt,/ kC{Phone Contractor's Name .0t / License"t44' Tse .. Phone �� TYPE OF WELLIPU P: NEIN 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 ❑ Open Bottom 0 Manteca .Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications.. + D Public Q Other ❑ Delta" Depth of Grout Seal Type of Grout " ❑ Irrigation --Approx. Depth ❑ Eastern Surface,Seal Installed by Repair Work Done ❑ Type of"Pump" H.p. State Work Done W y Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION © DESTRUCTION ❑ (No septic system permitted if publicsewer is O 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 depth SEPTIC TANK , /Mfg Capacity�,� No. Compartments �� PKG. TREATMENT PLT. ❑ _J i Method ofDisposal 47 Distance to nearest: v<a �! Fqundation, -- Property Line 1 LEACHING LINE .k5 N. & Length of lines - � d Total length/size � d FILTER BED ❑ Distance to nearest: Well Foundation Pro party Line r ; SEEPAGE PITS Depth .�1 S«� Size r f N)rrlber5 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 da a in accordance with Sa 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:"1",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-contrasting signature l 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 appli nt m call fo uired inspections. Complete drawing,,onreverse"side. 1 i Signed �� Title: Date: f ' _ FOR DEPARTMENT USE ONLY Application Accepted by lon,,14 OL Date ! Area o2L Pit or Grout Inspection by" ate Final Inspection by Date �4 i y Additional Comments:' 7 e-Zz- 73 i O Stk 466-6781 . ❑.Lodi 369-3621 C1 Manteca 823-7104'` ❑"Tracy — I Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT'DUE `AMOUNT REMITTED CAK RECEIVED BY �" DATE PERMIT`NO." f EH 13-24 MEV.10/83i 0 _7'p, "� N/(br EH•1428