SU-2601275_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Health District. I Job Address 6S � City Lot Size ��Q _ PM Owner's Name "✓ Address -_.� A a� — Phone 7-3 1? l .� r �/ Z Contractor's Name se No. Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f i PUMP INSTALLATION J SYSTEM REPAIR ❑ OTHER G If DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP, LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( ❑ Industrial ❑ Open Bottom 'D Manteca Die. of Well Excavation Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation JApprox. 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') ll! Depth _ Filler Material (Below 50) 10Inp TYPE OF SEPTIC WORK: NEW INSTALLATION 115 REPAIR/ADDITION ❑ DESTZOC ON INo septic system permitted if public sewer is v l ailable within 200 feet.) Installation will serve: Residence___ Commercial_ Other 0 Number of living units: Number of bedrooms Character of soil to a depth of3 feet: Water table depth . SEPTIC TANK 1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of D" Distance to nearest: Well Foundation Property Line LEACHING LINE Q9 No. & Length of lines _ Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line 2 0 SEEPAGE PITS ❑ Depth� Size N mbar SUMPS ❑ Distance to nearest: Well Foundation _ O v Property Line DISPOSAL PONDS. p 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 Heafth 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 applicart must call for II re red inspections. Complete drawing on reverse side.Signed (! Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 f7 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 RECEIVED BY DATE PERMIT N0. INFO CASH • EH 14-28EH 3-24 1REV.10/BCiI O O o