SU0006907 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601�E. HAZELTON AVE., STOCKTON, CA LE COPY 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 Ryles and Regulations of the San Joaquin + Local Health District. Job Address U r s Lot Size z' _-6>z �d CAD Owner's Name "�0 Address r Phone a Contract Address 1 ©, b� pC� License No..4ozGa(C) Phone 3k9-2011_ 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-1 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom t] Manteca Dia. of Well Excavation Dia, of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L) Public El Other'- ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed liy Repair Work Done ❑ Type-of.Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 4 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI /ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: !Number of b rooms ! `n Character of-soil to a depth of 3 feet: Water table depth C20 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' Jif LEACHING LINE No. & Length of lines B gd Total length/size x FILTER BED 1-1 Distance to nearest: - Well__..',�Z Foundation l D Property Line i, 4 SEEPAGE PITS ❑. Depth Sift Number SUMPS ❑ Distance to nearest: ,Wel Foundation Property Line DISPOSAL PONDS ❑ ;ep I hereby certify that I have prepared this application4arid°;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. , I Home owner or licensed agent's signature certifies the following: "I tpertify 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 st call for all r d inspections. Complete,drawing on reverse sAe. Signed Title: Date: FOR D PARTMENT USE ONLY Application Accepted by Date Area .Pit or Grout Inspection by Date Final Inspection by + Additional Comments: 1 ❑ 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 CK# RECEIVED BY DATE PERMIT"NO. CASH + EH 13-24 1REV.f/B51 EH 1126