SR0081401 SSNL - 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. Job Address _ City 4p Lot Size 'i`� g PM_ Owner's Name -RGO-1 Address 112-0/ V �(,�,� Gt {wG" Phone Contractor's Name License No. � � _ Phone3i�Wf�,? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ___ DISPOSAL FLD. PROP. LINE ' ` FOUNDATION _. AGRICULTURE WELL OTHER WELL PETS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing,_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. � ❑ Irrigation —Approx. Depth C Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 'P a' "-_ Fille7 Material iBeiow"i�OI _- . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I- DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.)' Installation will serve: Residence Commercial__ Other # 1 Number of living units:--I— Number of bedrooms"" �" " Character of soil to a depth of 3 feet: r Water table depth I SEPTIC TANK Type/Mfg. Capacity �'CrZ� No. Compartments i PKG. TREATMENT PLT.❑ I " Method.of-Disposal Distance to nearest: . Well r�+ Foundation o r tt l kperry.Line _JI_ , r, + LEACHING LINE e--No. & Length of lin j Total length/size +�0 FILTER BED ll Distance tofnearest: Well, 00 r Foundation IJEF � i Property'Linea ! SEEPAGE PITS C?,--Depth4_,�� Size �3 _ Number,.::�3= a _ _ SUMPS [I Distance to'nearest: Well .Foundation 1 c5 ��Property Line 3 ) DISPOSAL PONDS ❑ f ; 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. } jo J Home owner or licensed agent's signature certifies the following: "I certify that in theperformance 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'6vs4f-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 person's subject to workman's componsa- tion laws of California." j - 1 ' ; f The applicant must call for all squired in ec' S. omplete drawing on reverse side. Signed K_ _ Title: &A,\ 01 i Date: FOR DEPARTMEN7'USE ONL` II I Application Accepted by 1 Date _ , Area Pit Grout Inspection by� ate 1(25 _Final Inspection by Date dddd Additional Comments: ❑ Stk 466-8781 ❑ Lodi 3159-366 ❑ Manteca 823-7104 ❑Tracy-835-8385 n• r ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Mimi" imi Stk7CA 96201 1 } FEE INFO AMOUNT DUE AMOUNT"REMITTED - -~CASH _ RECEIVED BY" DATE" 'PERMR NO. l +EH 13-20 PREY. EN 14,7E 1 O 17