SR0080570 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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."frewage o. 18621or welt/pump and the Rules a�uiations of the San Joaquin Local Health District. J , " �u"L, � nLk/ ri Job Address of Size 2,0 M!-_�-- {' Owner's Nam Address Phone j.___� -� 1-- Contractar� Address !" License No.f�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLO. PROP. LIME FOUNDATION AGRICUL U WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D. Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ci Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50') Depth Filler Material IBalow 50') TYPE OF SEPTIC WORK: NEW INSTAI,�ATIO 1 REnB iR/�ON 1 S DEST ' TI N l 1 (No septic system permitted if public sewer is �V /� V available within 200 feet.) Installation will serve: Residence_ Commercial ! Other �,,, Number of living units: Number of bedrooms--•/�io ei� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ZZU No. Compartments PKG. TREATMENT PLT. ❑ t Method of Dispos+pl Distance to nearest: Well_.--- Foundation �� Property Line d U LEACHING LINE ❑ No- &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1s1s Foundation — Property Line Sd Ll SEEPAGE PITS 1 ', Depth SizeNumber _ SUMPS 0 Distance;to nearest: Well Foundation irk J Property Line DISPOSAL PONDS ❑ 1 hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws,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, 1 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." i The applican ust call for all required inspections. Complete drawing on reverse side. Sr Signed X _ Title: - �'L_ `Date: FOR DE FA TMENT USE ONLY Application Accepted by Date Area (Pik or Grout inspection by Y DateFinal Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 K# ' FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED 9Y DATE PERMIT NO, INFO CASH /t �/{ EH 13-24 tREV.t i N to i t1 b i�/ 0� D� EH 1426