SU0000240 - Laserfiche WebLink

Home Browse Search

APPLICATION run rcrl"' r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELi ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) application is /or install the rk Application is hereby made to the San Co Joaquin Ordinance Health 5District for sewage or rNo. 1962 fort to cwell/dpump and the Rules and hereindescribed. of he San Joaquin made in compliance with San Joaquin County yj,b al Health District.'/ �� f� Lot Size PM `Y e, /` O City Address Phone ` — Owner's Name� �IGr — Address License No. Phone Contractor Address WELL REPLACEMENT ❑ DESTRUCTION ❑ YPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES -- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION _�— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications f Casing ❑ Domestic/Private El Gravel o Gravel Pack ❑ Tracy Type of Grout I-I Other F 1 Delta Depth of Grout Seal L"1 Public Surface Seal Installed by — I I Irrigation Approx. Depth 1 I Eastern State Work Done _ H.P. ! C) Repair Work Done L7 Type of Pump Sealing Material (top 501 Well Destruction ❑ Well Diameter Filler Material (Below 501 DepthT` available within 200 feet.) TION I 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALL' Installation will serve: Residence — Commercial — Other_-- Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments ❑ Type/Mfg Capacity SEPTIC TANK Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well Total length/size LEACHING LINE Ll No. & Length of lines Foundation Property Line -� FILTER BED El Distance to nearest: Well SiNumber SEEPAGE PITS I I Depth _ ze Foundation Property Line SUMPS L I Distance to nearest: Well DISPOSAL PONDS 171 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, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 sign not employ any person in such manner as to becomcofthe workafor wh chthis permit ation is ssueds of !fl shall employ apersons rsubjecring t to workman!scompensa certifies the following: "I certify that in the performance tion laws of California." The applicant must call for all required inspe ions. Complete drawing on reverse side. O 7 Date: �igned Title: X FOR DEPARTMENT USE ONLY Date Area Application Accepted by Dat /;�Vt Pit or Grout Inspection by Date Final Inspection by e A ditional Comments: wa QR t KStk 466-6781 Lodi 369--WI ❑ Manteca 923 7104 ❑ Tracy 935-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED INFO ♦ EH 13-24(REV.I/A s) JS EH 14-29