SU0006308 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA �! Telephone (209) 466-6781 . PERMIT EXPIRES 9 YEAR FROM DATE ISSUED � � (Complete in Triplicate) IiNNED Application is hereby made to the San Joaquin Local Health District for a ,i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18M for well/pump and the Rules and Regulations of the San Joaquin permit to construct and/or install the work herein described.This application is Local Health District. I, l Job Address City PM a Lot Size !� Owner's Name o2 �� Address t'I fVte,- Phone�� 7 Contractor's Name �, i I License No. jl TYPE OF WELL/PUMP: NEWWELL ❑ Phone WELL REPf_,gCEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION WfSYSTEM REPAIR ❑ € DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. FOUNgATION AGRICULTURE WELLPROP• LINE INTENDED USE OTHER WELL PITS/SUMPS ! TYPE OF WELL PROBLEM!. ❑ lndustnal - R� CONSTRUCTION SPECIFICATIONS ]]1 ❑ Open—Bottom ❑ Manteca Dia- of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public q Type of Casing . ❑ Other ❑ Delta Specifications 1511 Irrigation 1i Depth of Grout Seal T ---Approx. Depth ❑ Eastern S �ace Seal' Installed Type Grout Repair Work Done ❑ f d by Type of,Pump. H.P. �/y j Well Destruction ❑ Wel! Diameter State Work Done Sealing Material (top 501I _ i Depth` !lFiller Material (Below 501} € TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No se tics 6 I P system permitted if public sewer is Installation will serve: Residenceavailable within 200 feet.} -' - ----— -____-�— Commercial- Other Number of living units: Number- - -- a of bedrooms Character of soil to a depth of 3 feet. SEPTIC TANK ❑ Type/'Mfg Water table depth PKG. TREATMENT PLT, ❑ �i� Capacy_ it . No. Compartments Method of Disposal Distance to nearest: Well Foundation I , !I Property Line ! LEACHING LINE ❑ No. &'`Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Total length/size q .;:Iii Property Line 4}� , I`. SEEPAGE PITS ❑ Depth SUMPSn Size Number !' ❑ Distance to nearest: Well I DISPOSAL PONDS ❑ Foundation Property Line f €` 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: employ any person in such manner as'�to become subject to workman's certify that is the performance rn the work for is hi this permit is issued, I shalt not certifies the following:"1 certify compensation pen laws of California."Contractors hiring or sub contracting signature rtify that tri the performance of file work far which this permit is issued,I shall employ persons subject to workman's com tion laws of California." `�I pensa The applica ust call for a1l r red in ctions. Complete drawing on reverse side. Signed 101- Title: Date: OR DEPARTMENT USE ONLY € € Application Accepted by 7 U r Pit or Date Area Grout Inspection by i� Date Final Inspection by Additional Comments: �N Date 4` ❑ Stk 466 6781 ❑ Loth 369 36'11 Applicant ❑ Manteca 823 7104 ❑ Tracy 835-6385 pplicant- Retum all copies to: Environmental Health Permit/Servioes 1601,E: Hazelton Ave:, P.O. Box2009, Stk., CA 95201 d !� FEE AMOUNT DUE ,j INFO 1 AMOUNT REMITTED. CK* RECEIVED BY CASH DATE PE +EH 1324(REV.70/831 �y J� f/}� I! RMIT'NO. j EH 1428 /�' • �• .... P