SU0004481 (3) - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT USAN JOAQUIN LOCAL HEALTH DIS1*CT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,/ [/ Job Address 4x 7 / � ��y Citlp4��d<dSize X/0 � pM Owner's Name Address Phone �~ Contractor � Address _47X' License No.�3��Phone 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 f"1 Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelo •1 (� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( DES79£UCTION I I (No septic system permitted if public sewer is __5_ available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: � Number of bedrooms / Character of soil to a depth of 3 feet: z Water table depth r SEPTIC TANK ❑ T ype/Mfg rJG Capacity /� No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disppsal Distance to nearest: Well Foundation Y/0 Property Line /d 7�- LEACHING LINE C,1L No. & Length of lines - C Total length/size 49 FILTER BED ❑ Distance to nearest Well/fJ"n Foundation ,L�a Property Line SEEPAGE PITS Al Depth -2 5- Size—_- 6 N mbar SUMPS ❑ Distance to nearest: Well /�/] Foundation �jh z`- Property Line �0 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 Diltrict. 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: "1 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 s call f all requ ed inspections. Complete drawing on reverse side`. Signed X ✓` Title: Date: FOMENT USE ONLY Application Accepted by � 31- `+� Date Area J O Pit or Grout Inspection by Q Date Final Inspection by ,r _ 1 ✓Date Additional Comments: -U� c�wjb J 0gel ,@ pa- ❑ Stk 466-6781 ❑ Lodi 36&3621 t3 MkAteca 823-7104 ❑ Tracy V 835-6385 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 CASH RECEIVED BY DATE PERMITNO. •.EH 13-211REV.r i x al `70 -CIO 11 1 13-31-8p ODF---71V3 EH'