SU0005755 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT \ SAN JOAQUIN LOCAL HEALTH DISTRICT C� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (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 plication is ` made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well and the rIt egul i f a pn Joaquin Local Health District. Jab Address City r Lot Size PM Owner's Name CD>U a r _.._..___.. .._.. dress Phone Contractor / 'icen_se No. / Phone �/ ^ TYPE OF WELL/PUMP: , NEW WELL,$U WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATfON,�?j_. rSV�TREPAIR-❑ .-- OTHER ❑ DISTANCE TO NEAREST: SEPT;fC TANK SEWER LINtS DISPOSAL FLD, �. FOUNDATION PROP. LINE AGRIGULFURE NVEtf_ OTHER WELL PITS/SUMPS I� INTENDED USE TYPE Oei WELL PROBLEM AREA 1 CONST-4 f -� ❑ industrial - UCTIONa:$PECIFICATIONS ❑ Open Bottom l `�! ❑ Maniea.-�—. 'Dia. of Well Excavatidr* Domestic/Private �Gravel Pack i I El Trac : Dia. of Well Casing/ Y i Type of Casing' L M Public ❑ Other ❑ Delta' Specifications .—�Q „i Depth of Grovt"Baal ! I Irrigation 1✓6Approx: Depth' I I Eastorn '` - Type of Grout w,G Surface,Seal'Installed, by - - + Repair Work Done ❑ T ype of Puht�"' -"'-f{.- P---_"} _ State Work Done_ Well destruction ❑ Well Diameter;' _;' Sealing Material (top 50') Depth _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION !.1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is Installation wiavailable within 200 feet.) Residence� Commercial— Other, ' Number of living units: mber of bedrooms Character of soil to a depth of 3 feet: i SEPTIC TANKWater table depth ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Faun a " -Property Line LEACHING LIME .❑ Ne. & Length of lines FILTER BEDTotal len ize, ❑ Distancg to nearest: Well ` Foundation Property Li SEEPAGE PITS i I Depth Size SUMPS Number ❑ Distance to nearest: Weil Foundation DISPOSAL PONDS ❑ property;Line 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, rules and regulations of the San Joaquin Local Health District. and Home owner or licensed agent's signature certifies the following: employ any person in such manner as to become subject to work "1 certify that in the performance of the work for which this permit is issued, I shall not man'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 aha!!em to tion laws of California." p y persons subject to workman's compensa- Th9 applica II t r all re spections. Complete drawing on re er ide. l Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date j Z / Area Pit or Grout lnspecti y pate ! Fina! Inspection b� Dat��'1��- Additional Comments: [de r.�r+tc f'`u., d rr�—r`� l rc(� f i` 17 J.�C+,, h--+ 1 6-e ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Tracy A3 e. , P.O. Box 2009, Stk., CA 95201 �)7-2- FEE 7-2- FEE AMOUNT DUJ CK INFO AMOUNT REMITTED CASH RECEIVED BY GATE 1 PERMIT'NO. + EH 13-24(REV.�i x 51 U(J �(�J J( �7 EH 11-29 `-'�' - 1