SU0007417 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE COPY (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereini7described:Thistapplication 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. [3AA,7-4 ` v Job Address = � _� ,-,,F_7 City as %- ZIA Lot Size 10V k14P'6PM Owner's Name])A /U 130)UAAAV Address Phdne Contractor + ZZtwF9— Address - T +6e License No. :?5�:S`5�� Phone TYPE OF WELLMUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER' ❑ DISTANCE TO NEAREST: SEPTIC SANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL l PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECI.FICATIONS ❑Industrial L7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public C-1 Other Fl Delta Depth of Grout Seal Type of Grout I ! Irrigation —.Approx. Depth I I Eastern, Surface Seal Installed by _ Repair Work Done '❑"' Type of Pump H,P. State Work Done , l . Wellt Destruction O Well Diameter Sealing Material (top 50') Depth Filler Material (Below W') TYPE OF SEPTIC`VVORK: NEW INSTALLATION l7 REPAIR/ADDITION I DESTRUCTION ( I (No septic System permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A Po 13L7 a Water table depth SEPTIC TANK .. ❑ Type/Mfg a Capacity No. Compartments PKG.-TREATMENT PLT'.❑ r F.7Method of Disposal Distance to nearest: Well _ Foundation a Property Line LEACHING LINE ❑ No. & Length of 1i'!1as __Z7.. ( d'. Total length/size !'7 FILTERBED Distanee to ineare'W Well ' Foundation Property Line ' SEEPAGE PITS I I Depth - Size Number SUMPS Ll Distance to.nearest: Well Foundation ProgortV Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this apptjration an tat the work will be done in accordance rfvrth San aoaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local HeaIh-bistrict: € Home owner or licensed agent's signature certifies th64ollowing: "I certify that in the performance of the work for which this permit is issueda I sh'alf`'riat employ any person in such manner as to become sub. ct to workman's compensatjpri'laws of California'."Contractor's hiring or sub-contractirig signature 'certifies the following:"I certify that in the performance of the work for which this'permit is issued,I shall.emplay persons subject to,workman'sicompensa- tion laws of California." The'applicant must call for all required inspections. Complete drawing"on reverse side, pp F Signed X r •Title: Date: { FJJk DEPARTMENT USE ONLY Application Accepted by r Date Area Pit or Grout Inspection by Date Final Inspection by Data . ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 IFEE �^'AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED 9Y DATE PERMIT'NO. i EH 1324(REV.1/M 5) EH 14-2B ��`—^