SU0005977 - 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 TYEAR 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 warn dlEW-aq.tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ruie Regin Local Health District. Job Address City Lot Size PM Owner's Name l . Address Phone ? Contractor e ` Address , icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER )U"1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. . . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial 0 Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of'Well Casing 64 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other C] pelta Depth of Grout Seal Type of Grout _ I I Irrigation ..Approx. De thl,l I I Eastern Surface Seal Installed by _ Repair Work Done it Type of Pump _ _ H.P. � StateAWork Pone" ` '\ Well Destruction ❑ Well Diameter 44" Sealing Material [too 50'1 AliA (_k, Depth Filler Material '(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I :DESTRUCTION I I (No septic";system permitted if public sewer is "\ available withiri.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 D Type/Mfg ` Capacity No. Compartments PKG- TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total iength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: , Well' Foundation Property Line 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."Contr ctor'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�ersons subject to workman's compensa- tion laws of California." The app:7StQ*.1lJfor all required inspections. Complete drawing on re se si e. Signed w Title: N Date: —1" /l/ FOR EPARTMENT USE ONLY Application Accepted by o Date 61""1/7`-,02 Area Pit or Grout Inspection by Date Final Inspection p Additional Comments: w ❑ 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 2049, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13 EH 1�-24 2B(REV.6x51 f� l Q��7 < ��7 '?0-33