SU0007602 - Laserfiche WebLink

Home Browse Search

APPLICATION F,OR PERMIT n :�_ - I . . SAN JOAQUfN.LOCAL..HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTOiV, CA SCA�IT Telephone (209) 468-6781 I'D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED INT (Complete in Triplicate.) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo5.7h 1 1Eifilszcc 6 p �ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul s a tRetiOA ann Joaquin Local Health District. J 6�s Job Address i /. 1 Cit Lot Size PM Owner's Name Address , A). Gt✓ /y / / Phone Z Contract 2 �r 2 r l"c1 Address in f/ oy 7�y �X• --Z, License TYPE OF WELL/PUMP: 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.,of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other © Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface.Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Material (Belo ') TYPE OF SEPTICWORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200'feet.) Installation will serve: Residence Commercial Other Number of living units:---I— Number of drop s _i:._, f ' Character of soil to a depth of 3 feet: Water table depth Gr SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line OQ SEEPAGE PITS Depth Size ' Number SUMPS ❑ Distance to nearest: Well_Z4:20.' Foundation__/f r Property Line 5- DISPOSAL PONDS ❑ ,. 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 permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant ust call for all req "red inspections. Complete drawing on reverse side. Y Signed Title: Date: I FOR DEPARTMENT USE ONLY / Application Accepted by � Date Area r 61 lY r Grout Inspection by Date Final Inspection by Oate Additional Comments: ❑ Stk 466-6781 ❑ 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 95241 FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + €H 13-24(REV,1/R5) y r EH W28