SU0002672 - Laserfiche WebLink

Home Browse Search

l / ' APPLICATION FOR PERM, ' # ` SAN JOAQUIN LOCAL HEALTH G._.RICT 1601 E. HAZELTON AVE.. STOCKTON, CA x 1 Telephone 12001 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r r a (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or irvrtall the work herein desaribodt.Ttds application n ' made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1882 for well/pump end the Rules and Regulations of the San.Josqufn rr Local Health Dlst . _ r r rlM City a � lot Size PM ae' Job Address = r ' Phone a. tl Ownees No A ' ' i ConsrectoPs Name License No. - 5 — Phone ti TYpE OF WELL/PUMP: NEN/W L Q WELL REPLACEMENT ❑ DESTRUCTION ❑ i+ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .': a J a DISPOSAL FLD. PROP.LINE -� '+ DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES _ FOUNDATION ""�AGRlCULTURE WELL— — OTHER WELL PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ° 'Indust '-' ---❑Open Bottoll F ❑Manteca Dia.of Well Excavation Dia.of Weil C (ng yy+1 .' a Specificavone,, 6 �j ❑ Domestic/Private, ❑Gravel Pack} p Tracy Type of Casio v A£ c ; ,. ❑jPublic ti ❑Other } ❑ Delta Depth of Grout Seal Type }at Grout .+ _ r 0 Irrigation: r, �' r —Approx. Depth ❑Easter Surface Seal Installed by 4i.k• State Work Done U ilepair Work_Done ❑ Type of Pump��— H.P. �' ro $t Sealing Material{top 50'1 ' ?k Wali Destruction: ❑ Well Diameter g r y, 2 '/ } Depth Filler h'sterial i"aw 601'} +,. x.x.. }:.! - Z - " p+ , o- TYPE OF SEPTIC WORK NEIN INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION D iNo septic system permitted If p lbllc sewer l9 17 { «<'1 z`available within 200 feet} ""i 2f" � { `"- 4r f/r T ,e Inataltatlon will serve;, Reafdtnce __ Commgrciat_ Other # ' ! C �?' fi t�Number of living units. Number at bedrooms - . -t- Water table depth ^` " l k Cheroeter of soil to a depth c 3 feet: ' } SEPTIC TANK;`. ❑ 'Type/Mfy Capacity No.Compartments !_ 3 Method of Disposal 3 Tri PKU TREAT'MENT.PLT.❑ K3 r. f/jtt Distance to nearest: Well Foundation Property Line a 4 4pr t a t "y r LEACHING LINE E3No.&Length of lines Total lengthlsize y k kms - yrP t. x'FILTER BED ' . Well Foundation Property Lina ; ❑ Distance to nearest: ... Y, f k a 5 SEEPAGE PITS Q Depth Size Number1.; ❑•: Distance to na,rest: Well '4 Foundation Property Line � �• ` �' ti DISPOSAL PONDS. ❑ Dlication and that the work will be done in.sccordancefw}�i'duari:ioaqulri•cburity ordinances state lows andw,- r ccerrtiity;That,l haus prepered'tftis'ap. .. .�t'rukw and regulations of the Sen Joaquin Local Health District. } `� `•jHome.owner 6encensed agent's signature certifies the following:"I certify that in the performance of the work for which this pew is fesued I;sltell not<r f 't -;'employ.any.person In such ntenr►ar as to become subject to workman's compensation laws of Califomia."ContrscW@ hiring or sub contrsetlnp afpnatun r ;cwd%s the following:"i certify that in the performance of ttha work for which this parol is issued.1 shall employ persons subject to workman t mpe�a-� e tion Ian's of-Califomlm" app�leettt must call r alt required inspections. Complete`drewing on reverse aide. .. F �' Title: Date: �".�. QQS .' 1 S ned E tg bi 1.`A2!ir .M. 4.••. i FCw..DEPARTMENT USE ONLY Appgcstfon Accepted by + Date„ Area 2 1 'Pit'or Grout Inspection by Final lnzpecticn by Date < r FA thenal Comments: ' h c $tlt, X88 67$1 ''.J ❑Lath .388-3021 Ma ,i 823-7104 ❑ racy Appgeant Rstum ell copies to:Envirorimenta Health Pamrit/Senricas 1801 E.Hazehon Ave., P.O.Box 2008,Stk.,,CA f1=1 r„ v N, r - v&`i' rY FEE " AMOUNT DU S `• AMOUNT REMITTED _ CASN REC[]VED BY DATE" f'£RFRR NO 4 ds r iPtFO. . ' Alit is .RFI. =rt�7 9M 144S N1 I v # 0 o #p.