SU0013585 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) ' X Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!the --0q0 17 Local work herein described. This application is Local Health District.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 lv'�," '' Job Address. l Ity Lot Size __ PM Owner's Name _ `ten 1-�- `Address nitiw �rZAI p�� { . Phone Contractor �� l t� I Address a?C jD8 C.', �� License 3 No.� Z Phonee9(C—6'14-CM TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ft-rA4a"V WQ((J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD.— PROP. LINE FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial O Open Bottom O Manteca Dia. of Well Excavationmoi` Dial. y • a. of Well Casing Domesti Priv Gravel Pack O Tracy Type of CasingTv r M� Public <- Specifications Q,t$ [� Other O Delta Depth of Grout Seai �A�\P-%A- ' I I Irrigation A Type of Grout +v gel'• ___ pprox. Depth I 1 Eastern Surface Seal Installed by Repair Work bone rl Type of Pump H P _ -- _ State Work Done Well Destruction ❑ Well Diameter, N Sealing Material Itop M Depth AIt 1 l Filler Material (Below 50'1 8 C!L' ,per TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIRlADDITION i I DESTRUCTION i I tNo septic system permitted if public sewer is Installation will serve: Residence CommercialOther available within 200 feet.l Number of living units: i._ Number of bedrooms_. Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth _ ❑ 'Type/Mfg _ PKG. TREATMENT PLT. O Capacity No. Compartments Method of Disposal _ Distance to nearest: Well_ Foundation Property Line LEACHING LINE ❑ No. & Length of lines - . Total length/size— FILTER BED ❑ Distance to'nearest: Well Foundation � - Property Line_ SEEPAGE PITS 11 Depth 3 Size_ Number SUMPS Ll Distance to nearest: Well _ Foundation DISPOSAL PONDS GI _ Property Lina _ 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: "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'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 shall employ persons subject to workman's compensa- tion laws of California." The apptica ust call for all required inspectfo . Complete drawing on reverse side. Signed Title: FOR DEPARTMEN USE ONLY Application Accepted by �� 7i Date Area Pit or Grout Inspection by Date_ y� Final Inspection by _ Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ' ❑ Manteca 823-7104 12 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. EH 1124 IREV.; EH 1426 3 S 1 C • O