SU0007346 SSNL - Laserfiche WebLink

Home Browse Search

.. APPLICATION FOR PERMIT SAN JOAQUiR LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 3 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 ,olf� the San Joaquin Local Health District. Job Address 3 � `� IV\� JA�J7 S Subdivision Name Owner's NameA_N ( \,�W�ddress Phone Contractor's Name E,E �f�1A\Z \ � icense No. , Phone ----1--0-- - TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ` a!� available within 200 feet.) Installation will serve: silence _ Commercial Other ^� Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: S R 1�� Water table depth CC)SEPTIC TANK ($ Type/Mfg C)1,,lr F Fita _ Capacity �,�Q�� No. Compartments PKG. TREATMENT PLT. Ln' Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well S,()• Foundation Property Line DESTRUCTION LEACHING LINE ( J No. & Length of lines Total length/size FILTER BED _ ❑ Distance to nearest: Well O oundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 workmant 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 ermit is issueq, I shall lAmploy persons subject to workman's compensation laws of California." The a it t ca 1 foo' `71Yegnreddinspections. Complete awing.oq�.yr-e-veerste 'de Signed " J Title; IEEE/4 P.IIY) ,�, Date: FO DEPARTMENT USE ONLY Stk 466-6781 Application Accepted by I Area ❑ Additional CommentAeto- t I, O r L �jl„ �^' ❑ Lodi 369-3621 Pit or Grout Ins peV�Date �Q ❑ Manteca 823-7104 Final Inspection brJ Date =+<F� ❑ Tracy 835-6385 Applicant - Return all. coEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82..500 EH 13-24 REV. 10/82 14-26