SU0004580 SSCRPT - 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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App rk .This cation is made nfcompliance weieby ithdSanJoaquin the nJoaquin County OrdinalHealth District for a nce No.549 for sewage or't to No. 1662 for construct ell//pump install nd the Rus and hereinR Regulations of the San Joaquin Local Health Diiissttriictt.�y /�/ yf/�) ..�^l Job Address,- / 7 A e-, /L-� ChO r' Lot Size PM Owner's Nam � Address � / '-�'�' � PhoneS --5 Contract r C Address /''� O2r767rr License No. e7(P Phone31vy-SiOb 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 O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residencev Commercial_ Other Number of living units: _,__ Number of� 00ms 4 / Character of soil to a depth of 3 feet: Water table depth D SEPTIC TANK W Type/Mfg Capacity No. Compartments 11 PKG. TREATMENT PLT.❑ I f Method of Disposal ->.J-t� i Distance to nearest: Well Foundation Property Line A LEACHING LINE No. & Length of line — Total length/size f) d' FILTER BED ❑ Distance to nearest: Well� Foundation r Property Line SEEPAGE PITS W Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation fA r Property Line Z:5� DISPOSAL PONDS ❑ 1 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, 1 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 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 in call for all re ue inspections. Complete drawing on rave rsq side. ��f n �j Signed X � Title: tIJ/ Date: lar of D 0 FOR DEPARTMENT USE ONLY Application Accepted by Date / " 2 Area Grout Ins by� � -- 6 C/ inspection By ate 6� Final Inspection ��' �e D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 21109, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ]DATE PERMIT NO. INFOCASH EH 1]-N(REV.I/x 5) 13 EH 147e