SU0012890 - Laserfiche WebLink

Home Browse Search

} APPLICATION'FOR PERMIT ti" SAN JOAQUIN LOCAL HEALTH DISTRICT . y. 1601 E. HAZEL(ON AVE., STOCKTON, CA_ Telephohe (209) 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 applicatiorti is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules araP&Uja"6Qs aquin Local Health District. r ��/moi QFT City t Size PM Job Address Owner's Name Address Phone Contractor ddress icense N Phone TYPE OF WELL/ U P: NE19 W ELL ❑ W L REPLACEMENT DESTRUCTION IK PUMP INSTALLATION 0 SYSTEM REPAIR © OTHER ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } f'k Public n Other Cl Delta Depth of Grout Seal Type of Grout . I I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done . © Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter; Sealing Material (top 50') III Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 XDITION 1.1 DESTRUCTION t I (No septic system permitted if public sewe( is available within 200 feet.) Installation will serve: Residence_: Commercial q Number of living units: Number of bedrooms 1 Character of soil to'a depth of 3 feet: Water table depth ! SEPTIC TANK -❑ Type/Mfg - Capacity. No. Compartments II PKG. TREATMENT PLT.Cl Method of i Distance to nearest: WellFoundation Property.Line LEACHING LINE ❑ No &Length of lines Total length/size I " '�aFiLTER-BED '�.- �"�F ❑ �-D,stance to nearest �-Well �Folindation �� '� =Prope f Ltne��' x�E i�,�� i;� ,��.�Y�x r„ ' .'..._ -, 1;.. �� .:�� iz�' ,fi'�� '?' •3;� �°r af-•1,s1tc+'�#'C=t�-W�'+Y�".y°+�. �'' �;"k�+��d'"'.{,{;ra��. � ,%„n.}�".�.CS e4d;�-�'W#•�� g SEEPPAG FIT fill i tp M sem`*S 1 'r� F f+lumher � a� c� , a.s 1'v'.� fX-° _Y.r.4 3t x'=Li�ti'GA� i}. .��Ar�-r e� .l'•^ 4 f�x'• �� k• - Sl7NtPS Distance tonearest�r WeEyl Foundatron Prope LEn «�' F !S_, AL P, BIDS Q �� et` prepar�th�appli anon s thai a rk�+rrl a tta an o8q u ortlina ate 1a atm: aSloa" U. 'local; eattFl D I - `:stgrlattere-- ;tte1>ti •� ceft t a - ;.pe - of;t s a tchper Y is , T1.r1oi c 5%,pbecomeyS bject�o' n,s��perlsa an rota Co ttacta a mng ar h su s arh+�f 'certify that the rforAnee q ar lkX7 la perm * emp pB ns subject o r:man Ir �' � `f��B�;a ,�=:�h 't�"r��vc.��.r ��,� � ,F• The applicant 1 a omplete,dra g onr SIdB.,� 3i' ()ate .y. , It. 'k 1�� ^^� i `" �' -`4" - ;•r•,•-• �r 7 ji fr s-.�..,.��.,�.1� -_-z. �t. : tak -r'^�,, '�'a :.r �`k "P ` FOR DEPARTMENT LISE ONLY { a r �.-k.' ,{�S'�PE tF. � a. �-`^ � a rr '' a !,i,'• a `x Application Accepted by, "Date Area rr t •, ��'. d'K ss A A,mt or Grout Inspection by Ina! inspect,orl by r Date �g Date � F �"� _Ad�dltlOnel Camnlent8 *' k r y- s k �5 jai A ',k : 4 ❑ Stk"466 6781' ,'❑ Lodi'.369-3621 ❑ Manteca`'823-7104 ❑Trky..;835 £ Applicant- Return'all copies to: En"ronmental Health Permit/Services 1601"E:Hazelton Aye., P.Q,`Box 2009,-Stk .CA'595201FEE ' INFO AMOUNT DUE AMOUNT REMITTED CASH CKO RECEIVED 8Y DATE :'PERMIVNO. 124(REV.1.1a5) R f 11.28