SU0005291 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 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 HealthDist�ict. Job Address a�� /fei liPy RA> ;4ion Name Owner's NameT �_� j gry�— Address Phone Contractor's Name --ii�LE� License No. 7ta�� Phone F TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ 00 PUMP INSTALLATION (_] SYSTEM REPAIR OTHER LJ (N DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �!n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public [j Other Delta Type of Casing Lj Irrigation Approx. Eastern Specifications Cathodic Protection Depth F-11atroecDepth of Grout Seal (]Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction [] Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION X. (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) ll Installation will serve: Residence Commercial _ Other d(- Number of living units: 4___ Number of bedrooms — Lot size �•�_� F� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ® Type/Mfg Capacity / y t _ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well _ � Foundation Property Line _ a� DESTRUCTION C] _ LEACHING LINE [—I No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line. SEEPAGE PITS Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be d6pe in.accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Al alth District. Home owner or licensed agent's signatur 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 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 ca ll uired inspections. Complete drawing on reverse side. , Signed X R-�•i/; T —. �itle: Date: FOR DEPARTMENT USE ONLY Area F-1Stk466-6781 Application Accepted by Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 'r O Z DATE PERMIT NO. / I-N FO {( 14 d.- _-) '02 S / 'W 10/82 500 v EH 13-24 REV. 10/82 14-26