SU0009318 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. O / Telephone (209) 466-6781 (gyp PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein J 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 of the S n Joaquin Locjl Health District. Job Address Subdivision New Owner's Na Address Phone Contractor's Name ° aar� License No. AC l/-Z!7 Phone4r^-1.2o Si TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] 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 I� Industrial (J Open Bottom M Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑Public ❑Other Delta T Irrigation Type of Casing V 9 Depth Eastern Specifications Cathodic Protection Depth � � ------ Geophysical Depth of Grout Seal Other Type of Grout 17 Surface Seal Installed by Repair Work Done [] Type of Pump H.P; State Work Done Well Destruction LJ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Bei ow SO') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION U (No septic tank of seepage pit permitted if public sewer is , b available within 200 feet.) Installation will serve: Residence Commercial _ Other `l �Ol1sM.Maww4. Number of living units: �_ Number of bedrooms Lot size / !.r(i Character of soil to a depth of 3 feet: Nater table depth ZO 7 -_ SEPTIC TANK Type/Mfg Capacity 171g_42X L No. Compartments 2-- PKG. TREATMENT PIT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 1400 Foundation �Property Line 16 DESTRUCTION .f LEACHING LINE No. a Length of lines Total length/size FILTER BED Distance to nearest: Well Are Foundation 16 f Property Line V` SEEPAGE PITS Xr Depth _� _ Size �j 3-7 ry Nunber � SUMPS LJ Distance to nearest: Well Foundation �Q f Property Line __ DISPOSAL PONOS CI I�Oyw/ 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: "1 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 this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant s�tf�d11 for all reyyyppp it insptions. Complete drawing omftyerse 5ige. // ?...• Signed % !/ �l Title: � w� Date: Y ENT US ` LY Area _Q�—_ ❑ Stk 466-6781 Application Accepted '+ Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date J Manteca 823-7104 Final Inspection by Date . ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 160 E. zeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT WE aMnUNT REMITTED RECEVEO8YE DATE PERMIT NO. INFO 4s� _ �� •'{ �� 10/82 500 EH 13-24 REV. 10/82 14-26