SR0085171_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2-24 +' Owner's Name Contractor's Name TYPE OF WELL/PUMP: - NEO WELL ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK _ FOUNDATION INTENDS — C' — Lot Size PM Addresso7� .Phone License No. �� — Phone vvt:r_L HIWLACEMENT ❑ DESTRUCTION O SYSTEM REPAIR ❑ OTHER E3SEWER*LINES _ DISPOSAL FLD. _ PROP. LINE AGRICULTURE WELL OTHER WELL— PITS/SUMPS _ D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ' + Ll Domestic/ Private EJ Gravel Pack ,•,� ❑ Tracy ; Type of Ca`smg`�'4 °�`�' "+—� - r - ❑ Public C1 Other Specifications L Delta Depth of .Grout Seal Type of Grout ❑ Irrigation Repair ._Approx. Depth ❑ Eastern Surface Seal Installed by_ ` J Work Dane ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 50') D�Pt1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L, (No system l optic permitted if public sewer is 1 vai a e wahin 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: --I— Number of bedrooms _� a Character of soil to a depth of 3 feet: SEPTIC TANK — Water table depth ❑ Type/Mfg PKG. TREATMENT PLT. C Capacity__ No. Compartments — Method of Disposal Distance to nearest: Well+ Foundation __ — P operty Line LEACHING LINE FILTER BED QY No. & Length of lines — ,T6tal length/size ❑ Distance to nearest: Wellham. Foundation, 112 LIk Property Line SEEPAGE PITS L1 Depth �; _ SizeI TM Number _ SUMPS Distance to nearest: Well!moi 1 f- Foundation �` J" - Property Line 17` DISPOSAL PONDS r . 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." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permitis-issued,71-shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title:- Date:-�3-� Application Accepted by Pit or Grout Inspection by --FJ138 DEPART T USE ONLY Date —` Area L Date Final Inspection by _ Dater / 4 Additional Comments: 3 Stk 466-6781 Ll Lodi 369-3621 C Manteca 823-7104 U Tracy 8355-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `11 FSE AMOUNT REMITTED INFO AMOUNT DUE S RECEIVED BY DATE PERMIT NO. a EH 1324 (REV. 10ra3)� I �S, �g ^EH 14-28. I 4t- `~ �1�']a�/d Lr Cil. �.,