SR0085397_SSNL - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT t t1 1601 E. HAZELTON AVE., STOCKTON, CA j+'` Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ r' ICamplete 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 707 City f Lot Size PM Owner's Name �4 _, Address Phone s .. 2 Contractor ' Address �_' __License No. Phone TYPE OF WELL/PUMP: _ NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U _SYSTEM REPAIR Lam' OTHER 71DISTANCE 70 NEAREST: SEPTIC TANK SEWER,LINES _ _..... DISPOSAL FLD. PROP, LINE FOUNDATION �.:._._......._ r AGRICULTURE WELL OTHER WELL _ PiTSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation _... Dia. of Well Casing ❑.Domestic/Private ❑ Gravel Pack 13 Tracy Type,of Casing . - _ __.. Specifications F] Public 1 Other Cl Delta Depth of CCrou# Seal _.�. Type of Grout I I Irrigation _ _.Aptirox• Depth I I EasternSurface Seal Installed by _ Repair Work Done D Type of Pump H.P., State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below.50') ._._...... _.._ TYPE OF SEPTIC WORK: NEW iNSTALLATION !.1 'REPAIR/ADDITION f DESTRUCTION-I'I fNo septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence Commercial __ Other Number of living units: Number of bedrooms 3 .r. Character of soil to a depth of 3 feet_ �aQ/1`L' K —� Water table depth V SEPTIC TANK ❑ Type/MfgJ009+'� Capacity /OZ-9� No. Compartments -- _. PKG. TREATMENT PLT. ❑ / r Method of Disposal /W Distance to nearest: Well 1„ Foundation._A? _. Property Litre LEACHING LINE CI No. & Length of lines _ _ _ -_ __ Total length/size v Y� FILTER BED ❑ Distance to nearest: Well_. ,�. __.. Foundation I Property Line SEEPAGE PITS I 1 Depth Size__ _......__.__. ___..`_.._.._._2..__.___ Number SUMPS L) Distance to nearest: Well �s Fcunda63n71 Property Line DISPOSAL 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 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 forwhich this permit is issued,I shall employ persons subject to workman's cornpansa- tion laws of California." The applicant must call for all required inspections, Complete drawing on reve a side. Signed XA .t :Y�v�'— ^6 Title: Date: + 0 RI 9.FOARTMNT U E ONLY-, -- Application Accepted by '• Hate /<i_1....(_ Area s Pit or Grout Inspection by - - Date Final Inspection by Ji'Y Date o Additional Comments: i 0 Stk 466-6781 D Lodi 368.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. ' . EHt3211REv,tfHSr �V! /�y S EH t4-26 , / �J pga O