SU0007122 - Laserfiche WebLink

Home Browse Search

E APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) il 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 of the San Joaquin Local Health District. !` I Job Address f /nf/V F City /� Lat Size !...__ -_. PM . } Owner's Name141AI / D/`1 Address)' C7 fo �� /►f F Phoned 6 `�Qi�O Contractor's Name �� _ License'No. S�"/`' 6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ 2'. WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION-❑ SYSTEM REPAIR ❑ f Y OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL=FLD.--_ PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELLPITS/SUMPS _— r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of-Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 4 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by q Repair Work Done ❑ Type of Pump H.P.' State Wo&Done Wel!-Destruction ❑ Wel! Diameter Seating Material (top 50') t : Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S I available within 200 feet.) { Installation!will serve: Residence Commercial X: other p Numberofliving units: -- -Number-of-bedrooms Character-of soil to a depth of 3 feet: C Water table depth SEPTIC TANK-';, j$( Type/Mfg r/Ziyy. S ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ i Method of Disposal . POO Distance to nearest: y Well Foundation Property Line LEACHING LINE ® No. & Length of lines Total length/size ei i e FILTER BED ❑ Distance to nearest: Well ! Foundation Property Line SEEPAGE PITS ❑ Depth Size F Number i SUMPS ❑ Distance to nearest: Well �'`O't� 7' 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. f 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:"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." I The epplica t call for all quire i pections. Complete drawing an r verse side. � Signed iN�!/�! /�„�— Date: Title: ��`� FOR',DEPARTMENT USE ONLY .�G- Application Accepted by �'" Date Area �0 r� Pit or Grout Inspection by Date Final Inspection by Date � 7 ! �.Additional Comments: C — r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca` 7104 ❑ Tracy 8354385 ± Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT"NO. +� +EH1 3-24 IREV.10!831 ._. � - _-, ,,•- - - - - � - p:J-�_ ._...... .^7 _ EH 1 i