SU0004520 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 3 PERMIT EXPIRES"I'YEAR FROM DATE ISSUED l� t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work ADS made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules San quln Local Health District. Job Address ,2 x111 ' _ City ,TJM0xl Lot Size 1 PM Owner's Name D "J 1) Address SAI-2' Phone "' --I " 00 Contractor Address _EQ, BOX 1T License No'71` 12-5 Phoned �1—�_ n TYPE OF WELL/PUMA: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION" SYSTEM_ REPAIR ❑ OTHER.0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 30 f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 �Iao-h— �7%bomestic/Private "Gavel Pack ❑ Tracy Type of Casing Dia. of Well Casing Specifications Fl Public n Other f1 Detta Depth of Grout Seal 100 Type of Grout l I Irrigation '23�Approx. Depth I I Eastern Surface Seal Installed by t s Repair Work Done .El Type of Pump _ fir. _ H.p - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 l Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION II REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is 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 ❑ .'Type/Mfg Capacit PKG. TREATMENT PLT, [] y No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length-of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundationw Property Line SEEPAGE PITS I I Depth Size Number SUMPS LlDistance to nearest: Well Foundation DISPOSALPONDS ❑ Property Line 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 i 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 rrianner as to become subject to workman's compensation laws of California."Contractor's 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: i'' ITE B Date: `—1.0-3�lr FOR DEPARTMENT USE ONLY Application Accepted by _._ Date V Area Pit or Grout Inspection by Dat.. Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 iApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO OUNT DUE ' AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT"NO. *.EH 13-24'REV-ria 5) _ID_ / GJ EH 14-2e l V _ lJ r co - w ` r-2 �'-