SU0011857 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON AVE., STOCKTON, CA I Telephone (209) 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 Address1 City�t / Size PM Owner's Nam. J�� Address Phone 1 1 —C&RM-H&sName �f!✓�� =T"N1°vL.L[icense7Jo. 3 —�'��"��""'�""-'- phone sd TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. UNE .. -FOUNDATION-----------AGRICULTURE-WELL--- OTHEFLWELL " -- PITS/SUMPS_ -_— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Prlvats ❑ Gravel Pack ❑Tracy Type of Casing_ Specifications ❑ Public ❑ 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 Dona Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') --+- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No s]Cmprtirrlerrts m permitted if public sejls �� availa00 feet.l Installation will serve: Residence__ Commercial l�ther Number of living units:_ Number of bedrooms Character of soil to a depthof 3 fest: - - e depth SEPTIC TANK ❑ Type/Mfg Capacity Lamin ts PKG. TREATMENT PLT.❑ i Disposal Distance to nearest: Well 0 Foundation J__I�_ PropertLEACHING UNE ��No. 8 Length of lines Total length/s FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SEEPAGE PITS N,-Depth 3 Size Number SUMPS ❑ Distance to nearest: WeII Foundation 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perm is issued, I shall not employ any person In such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature vern�ies the following:"I certify that in the pertormance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion Tlevila,of California.' applica at call o requ ins tions. Complete drawing an arse slicip. Q Signed Tile: Date: " R DEPARTMENT USE ONLY er qL� Lj Application Accepted by n..M_ � "`•�`^^^�'4'^� Date Area Pi or Grout Inspection by - Dete Final Inspection by Additional Comments: G Stk 465-67EI1 ❑ Lodi 3643621 `T] Mantera,823-71041 ❑ Tracy 836-61&5 Applicant- Return all copies to: Environmental Health PenNt/Services 1801 E. Massillon Aw., P.O. Box 2009, Stk., CA 95201 I s FEE AMOUNT DUE AMOUNT REMITTED K s RECEIVED BY DATE PERMIT NO. INFO CASRC/ . EHNI .loin) 04 4 4!S00