SU0004580 SSCRPT - Laserfiche WebLink

Home Browse Search

%we APPLICATION FOR PERMIT lr/ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q09) 466-6781 PERMIT EXPIRES 1 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. Job Address yU Q t•' "`^' `-�t •""' City— Lot Size �O O-t -7 PM Address JZ`SC1"'K Phone Owner's Nam (� Contract Address IF 0• Q 1�D 1 License No. ��Z�� Phone 3�g-S(OS 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O f"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ _ •� 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 "(ler Material (Below 501 I, n TYPE OF SEPTIC WORK: NEW INSTALLATION I 1EPA( ADDITION 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 room ��.x I Character of soil to a depth of 3 feet: ry "f Water table.depth , t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line f / LEACHING LINE No. & Length of lines —Lk 0 Total length/size I I FILTER BED ❑ Distance to nearest. Well- Foundation 10 Property Line �+ f I SEEPAGE PITS 11 Depth -7 Size— W X 10 L_ Number SUMPS >< Distance to nearest: Well 100r Foundation r �� Property Line 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 Di3trict. 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 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 b t call for 1 eq ed inspections. Complete drawing on reverse skid/�{(�� 4 Signed X Title: V: f Date: �� 1 FOR DEPARTMENT USE ONLY ApAication Accepted by' Date` � //!t�/hR-�Cfa 2—Area o Grout nspection by ate i rnal Inspection by Dore ✓��y2 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 CASH RECEIVED BY DATE PERMIT NO. EH EH 142a4-n