SU0013545 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PE01T SAN JOAQUIN LOCAL HEAtrTil DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (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 Subdivision Name Owner's Name _ Address _ Phone Contractor's Name License No. Phone TYPE OF NEL/?UvP WORK: NEW WELL WELL REPLACEMENT DESTRLCTION11 i PUMP INSTALLATION 0 SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES i DISPOSAL FLO. _ PROP. LINE FOUNDATION �+, AGRICULTURE WELL OTHER WELL —T PITS/SUMPS INTENDED USE —TYPE-OF-WELL_PROBLEM AREA CONSTRUCTION SPECIFICATIONS — 17 Industrial U Open Bottom ! Manteca Dia. of Well Excavation L) Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public L Other Delta Type of Casing L Irrigation _ _ Approx. Eastern — — Specifications Cathodic Protection Depth -- — Depth of Grout Seal Geophysical ,. Tj'e oof'Grout L!Other ----- Surface Seal installed by 1 Repair Work Done ❑ Type of Pump _ _ H.P. _ State work Done I Well Destruction i_� Well Diameter _ —Sealing Material (top Sc Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Li (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other _ Number of living units: Number of bedrooms -_ Lot size Character of soil to a depth of 3 feet: — '— Water table depth V SEPTIC TANK L! Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity i_ _ Mcthod of Disposal Septic Tank 0 Disstance to nearest: Well Foundation Property Line Destruction _ — LEACHING LINE -_ L No. & Length of lines — Total length/size — —_ L FILTER BED Distance to nearest: Well Foundation i Property Line SEEPAGE PITS Depth Size ----Number— SUMPS , L' Distance to nearest: Well _ Foundation Property Line — - DISPOSAL PONJS !-1 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. Hw.c owner or licensed agent's signature certifies the following: "I certify that in the perfr,mance- of the work for which this permit is issued, I•shall not employ any person in such mo nner as to hecome subject to workman k 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 Fenrit is issued, I shall employ persons subject to workman's compensation laws of California." 1 The applicant must call for all required inspections. Complete drawing on reverse side. 1 Signed X Title: Date: FOR L'LPA.RTMENT USE ONLY Application Accepted by Area F-) Stk 466-6781 Additional Comments: _ - [j Lodi 369-3621 Pit or Grout Inspection by Date _ __ [� Manteca 823-7104 Final Inspection by��- Date V _ (� Tracy 835-6385 { Applicant - Return all copies•to: ' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE 1 A..VUNT "DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO., i INFO -- \% ' EH 13-24 REV.,.10;82 ' 10/82 500 14-26 j