SU0007422 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Ck_�v FTelephone (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. J Job Address-5//D Amc� City- � L Size . PM Owner's Name _ry AddressPhone E a ContractofAddress6t d ` � License Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Privaie ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public Ll Other 171 Delta Depth of Grout Seal Type of Grout i f I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by— Repair y_Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material flop 501 Depth Filler Material (Below 501 i TYPE OF SLPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION K DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 20.0 feet.) Installation will server Residence_ Commercial— Other Number of living units: —I— Number of b dr ms-_,_,_ �f Character of soil to a depth of 3 feet: - 0� Water table depth SEPTIC TANK O Type/Mfg V C acity No. Compartments } PKG. TREATMENT PLT. ❑ Method of Disposal (l Distance to nearest: Well Foundation _ Property Line F1F1LEACHING LINE No. & Length of lines _ T/otal length/size FILTER BED ❑ Distance to nearest. Well - �."i �" Foundation�.�_'�_ Property Line�_.__ SEEPAGE PITS Depth - Size , Number SUMPS 0 Distance to nearest: Well ..-.:;L Foundation t� 7� _ Property Line j F DISPOSAL PONDS ❑ 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 Di%trict. 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 f 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 rnust call f r II required inspections. Complete drawing on revers sida. FFF t Signed X Title: Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date //��// Area ( Pit or Grout Inspection by Data Final Inspection byLl1(.�CiL, Date C �� F Additional Comments: i ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F }t� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED EIY DATE PERMIT-NO. 1 ,.EH i3-24MfV.+iKsr vR�te�f 10^Zf7�r li EH 11-28 V J