SR0081080 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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/pump and the Rules and Regulations of the San Joaquin Local Health District. r _ Job Address S 4:Q City(�_ City Lot Size PM r Owner's Name /�1 WLG� ~✓5 Address L D -40`,%/� Phone Contractor 1 GGA Address_ / 1/�� /47,�4License No 0;25 Phone�lr� 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private F1 Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ 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 50') /►"/ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C' available within 200 feet.) 6 Installation will serve: Residence Commercial_ Other Number of living units: .. Number of bedrooms oZ Character of soil to a depth of 3 feet: :1,!9 t/,D Water table depth SEPTIC TANK ElType/Mfg 1 / Capacity�Ct,L�_ No. Compartments PKG. TREATMENT PLT. ❑ -, - d Method of Disposal Distance to nearest: Well d Foundation Property Line �d �y LEACHING LINE ❑ No. & Length of lines f r Total length/size f FILTER BED Distance to nearest: Well Foundation �O�' Property Line L ' r , SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well'. . Fpundation 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 1 1-11 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."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." f The applicant must call for all r quired i pection Complete drawing on reverse side. J l 7 r g�i� Signed X Title: G '�y Date: y '7y—`S� _ J. FOR DEPARTMENT USE ONLY Application Accepted by Date 7 V Area Pit or Grout Inspection by Date Final Inspection by Date 2—_2.q v� Additional Comments: ❑ 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, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEflM1T N0. +EH 9-24(REV.1 5J a 06 ` . .. EH 11-26