SU0006409 SSNL - Laserfiche WebLink

Home Browse Search

r" y 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 wont herein descraed.This application is x made in compliance with San J County OrfLnance No.W for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. .r L . Jab Address City Lot Siaa PM i l Owners Name ` i Address _- ,Contractor ress [ -/ / �ar_� License No. a Phoft TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑Open Sodom ❑ MantecaDia. of Well ExcavationDia.of Well Casing n ❑ Domestic/Private ❑ Gravel Pads 0 Tracy Type of Casing ,_,_ ,Specifications 0 Public ❑Other ❑ Delta Depth of Grout Seat Type of Grout yEl Irrigation Approx. Depth ❑ fasten Surface Seal Installed by Repair Work Dome ❑ Type of Pump H.P. State Work Done Wall f�ction. ❑ Welt Diameter Sealing Material(top 5U'1 Depth Filla Material(Below 54}'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence____ Commercial Other = Number of living units: Number of owns Character of soli to a depth of 3 feet: Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC,.TFiFATINF1tIT PLT.❑ Method of D�sposai g : Distance to nearest well go Foundation 12.. Property line f S p `LEACHING LINE ❑ .No. &Length of lines -tet :1Total length/size FILTER BED ❑ Distance to nearest wen Foundation Property Line SEEPAGE-PITS ❑ Depth _ Size Norther SU,MPS ❑ Mile to nearest: Wag d 'Foundation go Property Line 2- 5 DISPOSAL PONDS ❑ I hereby certify that.I have-prepared this applicition and that the work will be done in ac:oordance with San Joaquin county ordinances,state laws,and rules and regulations'of the San Joaquin Local Health District. owner.ot lkat s@d agent's sigriatwre oertiRes the following: "1 certify that it the perforrtrance of the work for which this permit is issued,i shall not employ bny person in'ikO manner as to become subject to workman's eojttpensatibrt lavers of California."Contractors hiring or sub-contracting signature certilres the following:"1 certify that in the performance of the work for which this permit is issued,I sing empiby.persons subject to workman's compensa- tion laws of CaGfomia." The applicant QPM t tali for required inspections. Complete drawing'on reverse side Signed Title: e'... ,...__ Data -' FOR DEPAI TMELYT USE ONLY 'Application Accepted by /� q Date l��T�OT Area ' Grout lrtspectiort by l7at��+�' r Final Inspection Date Additional Continents: I7 Stic 4668781 ❑ Lodi 369-Ml ❑ Manteca 82:3-7104 ❑Tracy 8354M 4 Applicant-Return all copies to: Environmental Health Permit/Services 1601 I- Hazelton Ave.. P.O. Box 2009. Stk., CA 95201 W. 11 - FM AMOUNT DUE AMOUNT REMrtTED NFO ASH RECEIVED BY DATE PERMFrNO. +6!'132rIBEv.rieal bo Air EH:f1-2B 1.1