SU0007488 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 . 549 for sewage or No. 1862 for well/ um f Local Health District, p p and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Non Job Address j y.� :r,,�r73 - -*� '� } _ City :U-OD-i. Lot Size PM Owner's !Name �d`r`s tf 1i '; %��im �V Address !jJ1 ri n Phone Contractor "�- �� Address_�I''J J3L% 1("-� - r, TYPE OF WELL/ License No. ' r7 Phone 1 , r' NEW WELL Q, WELL REPLACEMENT PUMP INSTALLATION p DESTRUCTION-0 TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ --� SEWER L1NE5'_,�__ DISPOSAL FLD. I PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca❑EDomestic/Private ❑. Dia. of Well Excavation Dia. of Well Casing „•. ...Gravel Pack ❑ Trac i F] Public Y Type of Casing Specifications 61 Ll Other 171 Delta Depth of Grout Seal I I Irrigation —.Approx. Depth I I EasternSeal Installed by Type of Grout F'11 Jf , r Repair Work Dont; ❑ Type of Pump H.P. Surface Well Destruction. State Work Done `-`' ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 7 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Other available within 200 feet.i Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANKO Type/MfWater table depth r g - PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Method of Disposal Foundation Property.Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation . --: Property Line ._.� SEEPAGE PITS l I Depth Size SUMPSNumber Ll Distance to nearest: Well Foundation DISPOSAL PONDS p Property Line • q 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: "1 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 must call for all re 'red inspections. Complete drawing on reverse side. Signed X OW QJ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grou Inspection by at `Q LJ� r 1 1 SLL Final,Inspecti by Date /7 Additional Comments: ` ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A`ve., P.O. Box 2009 Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'fJO. ♦ EH13-24tREV:tin51 G�- gid EH 14-26 f°L!