SU0005983 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 incompliance 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. 11 Job Address N. CityLot Size 4� � PM Owner's Nam O&Address 6 V?/V, / t+ at c Phone 0 7 U Contractor u -R6, ddress rJU�C /&9— License Nof�bs�.�Phone 9-0 , TYPE OF WELL/PUMP: NEW WELL WELL REPLA �`EMENT ❑ DESTRUCTION ❑ � -D I� PUMP INSTALLAT10 SYSTEM t{EPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK 22S?SEWER LINES yDy,,�ISPOSAL FLD;) " PROP. LINE FOUNDATION _,AGRICULTURE WELL ATHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Xopen Bottom ❑ Manteca Dia. of Welt Excavation K Dia. of Well Casing Domestic/Private ❑ Gravet Pack ❑ Tracy Type�f using ��P�e-Q� Specifications ❑ Public ❑ Other ❑ Delta Depth,o. rout Seal �� Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done X Type of Pump H.P. ±fes State Work Done Q Well Destruction ❑ Well Diameter .^�- Sealing Material",(Cop�50') Depth _4Obo Filter Material (BPI. w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I3k-rDESTRUCTION ❑ (No septic system permitted if public sewer is f t available within 200 feet.) nst Illation will serve: Residence_ Commercial Other 1 z Nu ,k r of living units: Numbero#bedrooms j Character o o a depth of 3,feet: / l" �" Water table depth SEPTIC TANK a/Mfg €Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearer#: Fou'davon Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation rty Line t SEEPGE PITS ❑ Depth Size. ; r Number SUMPS ❑ Distance to nearest: Well Foundation Property Line FDISPOrSAL PONDS ❑ I heretiy 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. F. Home' wner 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 LL certifie's 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 0 all fAla require inspections lete drawing on reverse side. I F, Signed X�/C� ✓T�FJ�"ECG Title�,� "v7/l.P�`� Date: "" 7 I! d FOR DEPARTMENT USE ONLY + Application Accepted by Date - el Area { + Pit or(`Grout Inspection Date Final Inspection by "" ti Date Additional Comments: ❑ Stkt 466-6781 ❑ Lodi 369-3621 ❑ Mante 623-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 I