SR0084985_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7;W . / ? .. -7_-=-q — —0 J _. cam_ /A .. Owner's Name __t _�• oOleS7 -w47-1 Address o;i 9 G' 6jeawr,4,A;gg- -re/Phone Contractor's Name — License No. 4 Pt;_t:!i7�2 Phone TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U SYSTEM REPAIR .9 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 L Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing C Domestic/ Private (- Gravel Pack ❑ Tracy Type of Casing Specifications C Public L Other ❑ Delta Depth of Grout Seal ....______-_ Type of Grout L Irrigation ___�4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiel (top 501 Depth _ Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION'& REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is aysi(atLe_within.200-feet.-) 6:Instailatian-will serve:.-6:Residence Commercial ` Other ..- Number of living units: 4— Number of bedrooms — Character of soil to a depth of 3 feet: '0 �G Water table depth 4i SEPTIC TANK Type/Mfg jq%"(L+ CapacltyL-No. Compartments, Disposal PKG. TREATMENT PLT. ❑M 4- MethDistance to nearest: Well _ _Foundation Property L ned ofd LEACHING LINE No. & Length of lines 4-4(Z' F� 4'.Total.length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ib � 7' Size &Jet "y Number SUMPS Distance to nearest: Well _ Foundation Property Line 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 Iowa of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,'l shall employ persons siubiect to workman's compensa- tion laws of California." _ ' . _ The applicant must call for al requir +inispections. Complete"drawing on rederae side. - t tr i Signed X a L. �� .- ^r ... Title: Date: --FOR,DEPARTM.ENT USE ONLY 7 y 1 _ Application Accepted by - " '! Date 1 Area D Pit or Grout Inspection by Dots Final In_ tion by "C Data t � � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .Applicant - Return all copies to: Environmental Health PermUServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 y 4, Eli 13.24 TREY. 10/83 EH 14-29 FEE INFO AMO t1NT DUE_ _ _ _ ,AMOUNT,REMITTED_.., C.CASH'IRECEIVE6,13y. DATE PERMIT NO.