SR0084795_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �7 r'' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR 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 Health District. L4 I /1l Owner's Name <<L r �%71 ' � Address 10,01 1 17 � cl e W ehtS Phone Contractor t j ris'I�es,S J,1,2 it J Address.-/ i U U11 PS_/%.71" fft icense No. � 001 J Phone `� TYPE OF WELLIPUMP: • NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION l SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD. 70 ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial Open Bottom El Manteca Dia. of Well Excavation Dia. of Well �oCasing mestic/Private ❑_Gravel Pack ❑ Tracy Type of'Casing_,�e�L _ Specifications M Public 171Other ❑ Delta Depth of Grout Seal ��l1 Type of Grout �ckt, t I Irrigation oia.ApproK; Depth I I Eastern S rlage Seal Installed by Repair Work Done ❑ Type of Pump iS+�b H. P. !' State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth Feller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION 11. (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial , Other Number of living units: Number of bedrooms Character of soil to a depth of 31eet: Water table depth SEPTIC TANK _ O Type/Mfg r- I- Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ 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 1 I: Depth Size Number SUMPS L1 Distance to nearest: Well'' Foundation Property Line nISPOSAI. PONDS ❑ 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 r 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." 1. The applicant must call for all required in tions. Complete drawing on'reverse side. Signed X_ Title: -- Date: Application Accepted by Pit or Grout Inspection by D�R��NLY Date Area Data Final Inspection�bY ._ %�� Date Additional Comments: y/ �{1%/ �i�a'L!� — -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ' ❑ Tra y 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, SM., CA 95201 . EH 13-2a IREV. , i As EHti26 FEEMOUNT DUE AMOUNT REMITTED CK 1. INFO CASH RECEIVED BY DATE PERMIT NO. jaSr o� 1�.03 k) FW v\ JV