SU-2601274_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. 11362 for well/pump and the Rules and Regulations of tho San Joaquin Local Health District.Job Address (q641l E _ 011+40M P-4 City LINyV�� Lot Size i00W--�1/ PM p _ Owner's Name 1 WIOTO KC Address i85,01 E �(J-ron 1 --- Phone ^i 10 L t Contractor Address License No. _Phone TYPE OF WFl 1./PUMP: NEW WELL Cl WELI REPLACEMENT [I DESTRUCTION I-1 PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial LJ Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack O Tracy Type of Casing Specifications F) Public fl Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation __.Approx. Depth t 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE. OF SFPTIC WORK: NEW INSTALLATION 04 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X_ Commercial_ Other Number of living units: I Number of bad r oms 2-Character of soil to a depth of 3 feet: C( � K Water table depth_�2O' SEPTIC TANK U Type/Mfg __ Capacity_ I~-1Ob G—+Al No. Compartments PKG. TREATMENT PLT. O / Method of Disposal Distance to nearest: Well 1� Foundation 100 Property Line (Dior LEACHING LINE ❑ No. & Length of lines _ z Total length/size t7 FILTER BED Cl Distance to nearest: Well �2S r Foundation 156' Property Line SEEPAGE PITS 11 Depth Site _- Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Diktrict. 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 shalt na�& 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 permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c I all to pections. Complete drawing on reverse side. ��✓ Date: Y_Z 3— fie)Signed X_`_ Title: ,�' FONEPARTMENT USE ONLY pp Application Accepted by IA � _ Date 9!fN Area ' p— Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: v ❑ Stk 466-6781 LI Lodi 369-3621 O Manteca 823-7104 D Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. . EH13-24(REV.1IN5) —70,10 EH 14-26 1