SU0014060 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT N� 1 SAN JOAQUIN LOCAL HEALTH DISTRICT D 1601. E. HAZEL TON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED vz (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 4 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 l Local Health District ` Job Address _ -A 9 9t� ' , �� L LFn reit! / A A ✓ ! City -f��4G S� r I nt SI>A Pu Owner's Name _-Ai ReT-.��!'/�" Addresses — Phone Contractor > Address•649 f/.:L/'[= /iliCi — - License No. Phoney' TYPE OF WELL/PUMP: NEW WELL ❑..- ` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ `; OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _4NTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom l7 Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 Specifications ❑ Public 7 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Feller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑' (No septic system permitted if public sewer is f available within 200 feet.), Installation will serve: Residence _ Commercial _ Other Number of riving units: _ -F— Number of bedrooms Character of soil to a dept of 3 feet: 1=9*2t2—%,Lid P— A, . - Water table depth � SEPTIC TANK Type/Mfg 0-0- — P1f-L— _ Capacity l ' p0 No. Compartments 1-- PKG. TREATMENT PLT. ❑ / }� Method of Disposal Distance to nearest Well 1920-6 Foundation Property Line /407— LEACHING LINE No. & Length of. lines 4b �'✓� Total length/size Z& X z-..__ FILfER, BED ❑ Distance to nearest: '., Well /ad f Foundation ;• V Property Line . SEEPAGE -.PITS _L-1- Deptti- -Number j SUMPS ❑ Distance to nearest:1<'%Well ` Foundation Property Line DISPOSAL PONDS ❑ A I I LI, I nereDy cartrty that I have prepared this applicationand that the work will be done in accordance with San Joaquin county ordinanceb, state laws, and rules and regulations of the San Joaquin Local Heahfi,District. \t I Home owner or licensed agent's signature certifies the fohowing: "I certify that in the performance of the work for which this permit is'issuW, 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 certHies 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." r V The applicant must call for all required inspections omplete drawing on reverse side. t Signed Tide:' dn� Date: 1; " FOR DEPARTMENT USE ONLY Application Accepted byDate — Area a Q Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk , 466-67Bi O Lodi 369-3621 ElManteca 823-7104 ElTracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 + EH 1324 (REV. tie s EH .26 E INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO,. f oo i J