SU0010780 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAOUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 2311- 715 Telephone (209) 466-6781 ` GATE ISSUED N9-�Lb$4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) + ' Application is hereby made'to the San JoaquinfCocal-Health District for a permit to construct and/or install the work herein described. This application is made in compl,'ii:ance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 forwell/pump and the Rules Lind Reg lati yj of the San loapu;.jn Local Health District. Job Address �� - Subdivision Name ' Owner's Name d Address Phone Contractor's 46 License No. 3��zL 6' Phone 0 TYPE OF WELL/PUMP WORK: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION❑ — PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑:Irrigation Approx. ❑Eastern Specifications Cathodic Protection ,. ❑ Depth Depth of Grout Seal ' ❑.Geophysical I' Type of Grout l ❑Other A Surface Seal Installed by n Repair Work Done ❑ Type of Pump H.P. State Work Done I ' ,Well Destruction ❑ Well Diameter Sealing Material (top 50') -- Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION [J- REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is - available within 200 feet.) ` Installation will serve: Residence _Z Commercial Other + Number of living units: ---Number-oT-btdr'doms A Lot size , Character of soil to a depth.of 3'feet: LP/�A Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.-© Type/Mfg Capacity. Method of Disposal SEWRGESYSTEM ;( istance to`fiearest`.w Well Foundat4on Ir, Property Line ' DESTRUCTION LEACHING LINE No. 8'Le -of lines --�l�C�[e: Total length/size I "�^"�"^� Property Line FILTER BED ❑ H 015tance to nearest: ell , Foundation Ltl P SEEPAGE PITS I Depth Size —�3 " Number ' SUMPS LI Distance to'nearest: Well Ing!�-Foundation Property Line _�/ t' 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: "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 workman§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 must call for all r uired inspections. Complete drawing on'reverse side. Signed X (lr i.J,�_f r Title: Date: •' �A-,.-f..��'� 17- ' FO DEPARTMENT USE ONLY �/Stk 466-6781 Application Accepted by J.r�! Area Saj/+, Lodi 369-3621 Additional Comments: ❑ Pit or Grout inspection b� Date ❑ Manteca 823-7104 Date ` p�[ ❑ •Tracy 835-6385 Final InspectioW..by - - ¢ aT t Applicant - Return all copies o: Environmental Health Permit/Services 160 . Ha elton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE - AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 44 x 10/82 500 EH 13-24 REV. 10/82 14-26