SU0002671 SSNL - Laserfiche WebLink

Home Browse Search

x t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA ^�l Telephone (209) 466,6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fCornplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to cons+ruct andlor install the work herein descrihed.This application is i' made in compliance with San Joaquin County Orclh:ance No.549 for sewage or No. 1902 for wslrlpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - 51 51-1 ��t✓1�—P- City_gS�_4LfLat Size- b �•PM Owner's Name - _ Address t '1+'i_. _ Phone k Contractor 1 G J„7 s�t''� Address- �' _t License No,� ono t r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.'_._— PROP.LINE FOUNDATION AGRICULTURE WELL ti OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ?` ".6 f i i ❑ Industrial ID Open Bottom Ci Manteca Lia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private L7 Gravel Pact: ❑Tracy^ Type of Casing Specifications ❑Other' :"' U Deka Depth of Grout Seal Type of Grout t '1' ❑Irrigation S ---Approx. Depth ❑ Eastern ', Surface Seal installed by 4 a. Repair Work Done' 0 Type of Pump ` H.P. State Work Done, ' Well Destruction'-!.'[D Well Diameter Sealing Material (top 501 Depth Filler Material(Below 501 r TYPE OF SEPTIC WORK:•.NEW INSTALLATION❑ REPAIR/ADDITION KDESTRUCTION L7 lNo septic system permitted if public sewer is available within�200 feet.) t Installation Will serve: Residence L Commercisi Other ` Number of.l-riving units:-/— `Number of bedTOOma. ' Character of soil to a depth of 3 feet: Water tale depth {{ r.. SEPTIC TANK ❑ Type/Mfg _ i_�+�� Capacity 5 V No. Compartments PKG. i VEA7MF':l'PLT.L� i.� -C (�$ t Method of Disposal 1 Distance to neareet: Well Foundation___ Property Line . ....... •--_ r , .v P S'Total len h/size ;.., LEACHING LINE � No.&.Lengtli of lines �;� fat FILTER-BED ❑ Distance to nearest: Well ZQ d undation_2,0_, Property Line •-r ,SEEPAGE PITS__ .• ❑ Oepth Size �=fX I��I�/_��Number ! SUMPS Distance to nearest: WsSI LQ n`'{- Foundation. 0 Property Line-2-31L4- DISPOSAL ine2-3 {'DISPOSAL PONDS ❑ I hereby,eenify that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances,state taws,and i rules end regulations of'the.San'Joaquin Local Health District. i ! Home owner o 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 1 . employ any parson in Such manner as to become iwbjact to workman's compensrtion laws of California."Contractoes hiring or subcontracting signature i i certifies the followiag:"I certify that in the performance of the work for which this permit is issued,I shat employ persons subject to workman's compensa- tion laws of California." 1 The applicant mustcall for all required inspections. Complete drawingfon reverse side. ` t I Signed _ Title: � nQ�:t�� Dm' " R DEPARTMENT USE ONLY f r EEI Dater ; 1 Ate. f + Application]Accepted by ' Grout e . - ....._ _. -. Date Final Inspection by Date 7 •r Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3139-3621 ❑ Manteca 823-7104 ❑Tracy B&5-6M5 Applicant-Return all copies to: Environmental Health PermitlServicw 1601 E. Hazekon Ave., P.O. Box 2009,Stk., CA 95MI )�3t FEE AMO.rNT DUE AMOUNT REMITTED CASH RECEIVED sy DATE PEAMIT'NO. 11 a EH 13-241REV. W - tiH 14.26 iia 7. Y•),r� -N �i',9�'s4s1v;'w;�s-:M:iRl�ii?:+.tC+{aewxNdli4.d- ;Mau.van�mns� w.r4«yiy- -sa rc,r,res..;,;•i �4.rY fir. �. tz rZ