SU0009706 SSNL - 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 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/pum and the Rules and Regulations of the San Joaquin Local Health District. �,/ Job Address ""— city Lot Size PM 71, Owner's Nam ` Address Phone C � �7gj Contractor's Nam License No. Phone / TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia.of Well Casing G Domestic/Private ❑Gravel Pack O Tracy Type of Casing Specifications �I ❑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 Done Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material IB low 50'1 AI TYPE OF SEPTIC WORK: NEW INSTALLATION C REPR/ADDITION DESTRUCTION L' INo septic system4 permitted if public sewer is ✓/ available within 200 feet.) Installation will serve: Rest once_ Commercial= Other �--y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: d"— Water table depth SEPTIC TANK fl Type/Mfg Capacity, ��/ No.Compartments PKG.TREATMENT PLT.❑ ) Method of Disposal Distance t ear Well ndatio Pr rty Line LEACHING LINE INK No.& o lines _4ea Total length/size Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS J-M-�epth -..Jr Size J Number Z SUMPS ❑ Distance to nearest: Well Foundation "d 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 a§__eecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certi a pe co of the work for which this permit is issued,I shall employ persons subject to workman's co - tion laws of California." The applicant must inspections.Complete drawing on raver Signed _"- ---- Title'_. Date: �? - FOR D > RTM T USE ONLY Ap icat Accepted by Date Area Pit or Grout Inspection by Date Final Ins ction by � P-�'I'� Data V Additional Comments: i"PAl41Y a� low 1 ❑Stk 466-6781 O Lodi 3621 O MantSca 823-7104 'D Tracy 8366385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 FEEINFO AMOUNT DUE . MOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT No. .EH 13-244REV.10/831 `j�I-. :•, 4 ''�� 'v� 5--i--4-/ ,yy-,t'P EH iL2a