SR0082189 SSNL - Laserfiche WebLink

Home Browse Search

r 1 APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., S`fOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' t ' (Complete in Triplicate) s r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.rTHs 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 D'istr'ict. Job Address � Citi' `-'-'� Lot Size �� PM -Owner's Name Address I j Contractor -- A3dress� �� :/1 1 License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ✓ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER'WELL._- -PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 7 Open Bottom [I Manteca o 'Dia. of Well Excavation Dia. of Well Casing G-Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing. _ Specifications ❑ Public ❑ Other [] Delta - Depth of Grout Seal Type of Grout_ ❑ Irrigation —Approx. Depth J Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H-P. — State Work Done I Well Destruction ❑ Weil Diameter Sealing Material (top 50') Depth Filler Material {Below 501 I TYP£-OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITIO DESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial_ Other—_ I Number of living units:( / J Number of bedrooms IJr Character of soil to a depth of 3 feet:_ -L-- Water table depth - ' opacity No. Compartments � SEPTIC TANK Type/Mfg _ —f PKG. TREATMENT PLT, C Method of Disposal Distance to nearest: Well _ Foundation_- Property Line LEACHING LINE No. & Length of lines _- Total.length/size FILTER BED Distance to nearest: Weil Foundation — Property Line tj SEEPAGE PITS Depth Size 6 Number _ -7— SUMPS ❑ Distance to nearest: Well Ztein Foundation Property Line LiL— 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 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 [I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring sub-contracting signature c 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- 1 tion laws of Califomia." The applicant must call for all req pections. Com to drawing on reverse side. Sign Title: �� ' _ Dater FOR DEPARTMENT USE ONLY Gf Date 1 -> _ Area Application Accepted by - k / P�[or Grout Inspection by Date v Fnai inspection by D —� /Additional Comments: C 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.D. Box 2009, Stk., CA 95201 I FES AMOUNT DUE AMOUNT REMITTED CASH CK# RECEIVED BY i. DATE PERMIT"N0. INFO J .EkJ3241REV,1/B5: �{s Eli 14-26 + i"