SU0005805 - 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 FILE C 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. r F � Job Address � V City SLIA Lot Size PM Owner's Name' l---- Addressy Phone U Contractor/ , D __ ess l/ /� License No./ O Jt� ia Phonr!_/ 0^Si 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing--- -- • Specifications 1-1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern i Surface Seal Installed by Repair Work Done l I Type of Pump __.J+P. State Work Done _ Well Destruction 11 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IAT REPAIR/ADDITION..LI_-DESTRUCTION I I (No septic system permitted if public sewer is � f__ available within 200 feet.) t y� Installation will serve: Residence�commercial_ Other Number of living units: Number of bedrooms N__ Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg IC V' Capacity_12 00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /0 0 Foundation-�J� Property Line l6 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /D b Foundation _�_4 Property Line 'l SEEPAGE PITS 11 Depth 2 Size , ` Number SUMPS L Distance to nearest: Well/�L Foundation 106 1 Property Line Z� 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." Contractor's hiring or sub-contracting signature certifies theIlowing: "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 alifornia." The applicant ust call or require inspections. Complete drawing on reverse side. Signed X Title: _ aev!05�L i Date: I FOR DEPARTMENT USE ONLY t Application Accepted by N_ Date 5- 33 t 13/ -i1 ! I Area Pit or Grout Inspection by Date Final Inspection bvl . .f U�'�t_N`� Date s �� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK CASH RECEIVED BY DATE PERMIT NO. EH 13-24(REV.I/H 5, rpt/ J �� EH U-26 I