SR0080542 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ✓/ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i 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/pump and the Rules and Regulations of the San Joaquin Local Health District. z I(Aljj, Z� / l�[� �/uTZ� / / % Oil .lob Address _ City�_ Lot Size Z PM Owner's Name �� f �-Address S Phone °'� — A(� ✓ 3 i Contractor /. Address _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O 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 G Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public r r ❑ Other, ❑ Delta Depth of Grout Seal Type of Grout G 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 Filer Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is ff available within 20D feet.) Installation will serve: Residence / Commercial_ Other i Number of living units: Number of bedrooms- 44 Character of soil to a depth of 3 feet: ti Water table depth �f T SEPTIC TANK Type/Mfg AW No. Compartments PKG:"TREATMENT PLT. O �r� Method of Disposal ti Distance to nearest:. Well ~ D Foundation Property Line _ LEACHING LINE No. & Length of lines '_ / Tg�a! lengthlsize �.b FILTER BED v Distance to nearest: Weii y��,°� FSundatiorf/ .—` Property Line SEEPAGE PITS Depth�'z'i" �.• , r. .l �� _,�j Nwnber_�=` SUMPS Distance to nearast; Well oundatron_ / Property Line: � � DISPOSALPONDS ❑ s 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 as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certh that in the perforrriance of the work for which this permit is issued,I shall employ pennons subject to workman's compensa- tion laws of California." The applirpKt must call for all required inspect' ns. Complete drawing on reverse side. / p/ tV\ t�: b — Signed X __ Title: Date: iJ FOR DEPARTMENT USE ONLY 07 Application Accepted by 4 Date Pit or Grout.Inspection by f Date Final Inspection by ^^^�� Date 0DWIE' Additional Comments: 11 ❑ Stk 456-6781. ` O Lodi'-'369-3621 ' C7 Mantem 823-7104 A Tracy 835.6385 Applicant- Return all copies to: Environmental Huth Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 ' IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. L . EH(321(REV.I1 5) �O C___ A �7O Qp : = - �'/L�/ g� Rra�1,53 EH 1425 w -