SU0004637 SSNL - Laserfiche WebLink

Home Browse Search

n. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reguiations of the San Joaquin Local Health District. r Job Address City Lot Size CU PM Owner's Name Address �1r'L p_ Phone '�¢ Contractor's,Name ' ' - - License No. � � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ FDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F. 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 Well Destruction Q Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 +' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is W available within 200 feet.) { Installation will serve: Residence— Commercial_ Other Number of living units:__/_ Number of be r ms -� ' e Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity f _ No. Compartments '" PKG. TREATMENT PLT, ❑ Method of Dii osal '_ L•�+ ` i. Distance to nearest: Well� Foundation Property Line" i LEACHING LINE No. & Length of lines Total length/size Yo - FILTER BED ❑ Distance to nearest: Well Foundation Z 0 t Property Line t SEEPAGE PITS Depth .Size 3� Number SUMPS ❑ Distance to nearest: Well Foundation /0 r+ Property Liner Q DISPOSAL PONDS ❑ i 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 `�1 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 F,} employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 must call f r all re dins ons. Complete drawing on reverse side. Signed + 10 Title: Date: l �� E FOR•DEPARTM NT USE ONLY F �i Application Accepted by Date /Tf�u Area or Grout Inspection by `��lX // Date Final Inspection by Date r tt l.Additional Comments: ❑ Stk 466-6781 _ ❑ Lodi 369-3621 El 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 AMOUNT DUE AMOUNT REMITTED CC4K5H RECEIVED 6Y DATE PERMIYAO. INFO I ♦ FW 13-24{REV.10/93I _ 1 1x.26 FW _-