SU0013610 - Laserfiche WebLink

Home Browse Search

• ,� r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-Ml 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, , S o ,r v4Y7 Job Address — City Lot Size ID PVCXZ-E-: PM Owner's Name ��` y& tSLAR Q Address 13S e-0�� v ` `1 � 1 Phone Z- r . - of Contractor's Name - L - License No. Phone ' V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLE - _ PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL -- PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing T "" "" "'"Specifications C Public ❑ Other ❑ Dena Depth of Grout Seal Type of Grout__ ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ^- M� available within 200 feet.) '~ Installation will serve: Residence_ Commercial Other M055kV Number of living units: Number of bedr ms Character of soil to a depth of 3 feet: __- Water table depth "f SEPTIC TANK 44 Type/Mfg r Capacity 1200(�No. Compartments PKG. TREATMENT PLT. ❑ _ � ,�/ Method of Disposal Distance to nearest: Well,.� t Foundation lot Property Line- _ � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BE Distance to nearest:..._. . WeII.�Q4 Foundation f2_0 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well�_ Foundation Property Line c 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the foNowing:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ) The appli t must II for all ►equir spections. C to drawing on reverse side. _�j Signed Title: 4!! ` Date: F R DEPARTMENT USE ONLY Application Accepted by' Date g Area r Pit or Grout Inspection by ;Date Final Inspection by Date Additional Comments: - - - - - - - - - - X'Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 /Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE UNT DUE AMOUNT REMnTED CK RECEIVED BY DATE PERMIT'NO. INFO (� CASH + EH 13-24(REV.10/831 EH 14-28 ll