SU0013225 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE' -TON AVE., STOCKTO CQp �} J r,�Cri Telephone (209) 466-6781 JR # PERMIT EXPIRES 1 YEAR FROM DATE IAMW Gj J (Complete in Triplicate) FA Application is tiefeby made to the San Joaquin Local Health District for a permit to construct an or ACt is made in compliance with San Joaquin County Ordina ca No. 549 for sewage or No. 1862 for Wei /I ut Rules and Reput tmn of the San Joaquin Local Health District. �� Job Address City Lot Size PM Owner's Name f Aderess�5��¢•ti dliytllT� .hnn.e 7 �11. 76 Contractor TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE ❑ Industrial ❑ Domestic/ Private .7 Public i I Irrigation Repair Work Done ❑ Well Destruction 17-. ddress ` / aJ S,r Phane01A14 License I IF NEW WELL F PUMP INS71ALLATION ❑ SEPTIC TANK SEWE FOUNDATION AGRI( TYPE OF WELL PROBLEM AR ❑ Open Bottom ❑ Mante ❑ Gravel Pack ❑ r06 M Othereta _. Approx. Depth I I Eastem Type of Pump F Well Diameter Sa Depth _ F IIe W,�LL REPLA;EblE�VT –I DESTRUCTION ❑ SYSTEM REPAIR Ll OTHER ❑ LINES DISPOSAL FLO,__ PROP. LINE �LTUR ELL OTHER 0,11-1 _ PITS/SUMPS TRUCTION SPECIFICATIONS Dia. of Well Excavation _ r. Type of Casing--__ Depth of Grout Sea! _ Surface Seal Installed by _ State Work Done ting Materia! !top F�)'I r Material (Below 50'1 Dia. of Well Cdsing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AOMTION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence — Commercial Other Number of giving units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth____ SEPTIC TANK L1Type/Mfg Capacity– No. Compartments PKG. TREATMENT PLT, ❑ }} L Method ofDioosal Distance to nearest: Well 6 'T oundation Property Line LEACHING LINE i_ 1 No- & Length of lines i qt length/ size FILTER BED Cl Distance to nearest: Well f ".undation�Q _ Property Line _ GE PITS I -3 1 Depth size bar T SUMPS ll Distance to nearest: Weil oundation Property Line _ SAL PONDS ❑ Z 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 Joaouin Local Health District. i 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." Contracto's hiring or sub-conifacting signature certifies the following: "I certify t'nat 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 !=X�:= rawing on reverse side. r Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 3 A L. Pit or Grout Inspection by D�ayte _ Final Inspection by Date -y _ 11f �Ji14_.t �- Additionrf Comments: 0 _� - ❑ Stk 466-6761 ❑ Lodi 369 3621Manteca SM -71 it Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box � S,Qpr2D144L EH 13.24 !REV. Fry 14-2a YEE INEO AMOUNT DUE AMOU REMITTED CK RECEIVEaBY DA 7r.