SU0010873 SSNL - Laserfiche WebLink

Home Browse Search

{ a APPLICATION FOR PERMIT r; If 4 SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601'E*,H%ZELT0N AVE',STOCKTON, CA Eh Telephonejt9) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 appikardon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.18M for wall/pump and the Rubs and Regulations of the San Joaquin Local Health District:: waw Job Address eq Q A6 city Let SaeZ 1413no PM Owner's Name Address LALoj Aoy �o'ZO per/ 1'��y ^...5 �Ta�•t _ i Contractor; �w� _ "1'"Address.- se No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ih )A PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DI STANCE?40;NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !I I! I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industri8l- I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic)1/P,i✓ate ❑ Gravel Pack C1 Tracy Type of Geeing Specifications �7 ❑ Publics ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q ❑ lrrigati 111 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destr6ction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material(Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _!� `` available within 200 feet.) " l ) Installation will serve: Residence-Y� Commercial— Other r, � Numbdr of)twang units:� Number of bedrooms__3 � Charecte)rof soil to a depth of 3 feet: Water table depth 8 SEPTICY NK4 g Type/Mfg CL�YC+QE`lL Fj/ Ceps airy L No. Compartments PKG. TREATMENT PLT.❑ r� y'4��., ;Foun�da'tot Methodof Disposal ""---`~"-"-Distance to nearest Weil , n� Property Line". - - - C + LEACHI!�Gl LINE W No. 8 Length of lines ' 'J - &C"Tootal length/sae FILTERIBEO• ❑ Distance to nearest: Well -'Foundation s_ _ Property Line SEEPAGE PITS ❑ Depth -Size Number SUMPS I j ,-� • (P Distance to nearest: Well Foundation Property Line V+ DISPOSAL.PONbsi 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. Homeowner or licensed agent's signature cant les the following: "I certify that in the performance of the work for which this pemtit is issued, 1, no \I employ any to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that.iin the performance of the work for which this perrn it is issued,I shell employ persons subject to workmen's compense- tion laws of Cal)fornilla '°• e. The applicant mu all required' s.iCom J drawing on reverse side. Signed - rt,q:, .�.!'1!✓�F3� Data: I,DEPARTMENT USE ONLY 1 1 Application11111,Assep3ed bYc_- �¢, �_Y�1, Data / / �O Area v .Pit or Grout snspectlonpy 4 DaFinal:,inspection by F:]' .v`"'-' Date '� 0 Additional CornmenB - At -tom 3v�4 --L _ _ ,:S?t�Mr W ❑ Stk 406-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 C -C❑47acy Il MS- 386 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2016, Stk., CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED 9Y DATE PERM11 NO. ♦EH 133 t/ea) EH t4.204ZB = �• a J+ • i