SU0007601 - Laserfiche WebLink

Home Browse Search

n_-APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I(Camplste in Triplicate) 11cirill. Application is he7eby made-to the San Joaquin Local Health District for a permit to construct and/or install the work her nt0li Patioyis 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. �, �j Job-Address 17,33& ,t h "v e City r Lot Siz (9at� PM i r Owner's Name. t&AAUh�) – Addresslea,� �e Contracto ` ' I Address l .vz 1.�C 7Lt77"c 'License No. EZ z Z� Phone_ TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE :- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE : t".",,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 F1 Public l l Other Cl Delta Depth of Grout Seal Type of Grout 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 1` Weh f?iameter Sealing Material (top 501 :Depth-" F.Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I EPAIR DDITION7. DESTRUCTION ( I (No septic system permitted if public sewer is r savailable within 200 feet.] Installation will serve: Residence ZC'ommercial Other Number of living units: Numbe"r of a rooms ;`Character,of soil to-a depth of'3 feet: A X Water table depth SEPTIC'TANK ` P . .Type/Mfg Capacity" No. Compartments ; I – . PKG. TREATMENT PLT.'.p.. Method of Disposal Distance to nearest: Well Foundation Property.Line " s LEACHING`L1NENo. & Lengt�l of lines �'— 4/D Total length/size Z FILTER_,BED_ ❑, Distance to neatest:` Well `? / Foundation __40 Property Line SEEPAGE PITS Depth Size + -f :1 Number SUMPS ❑ Distance to nearest: Well:1bJz Foundation Property Line DISPOSAL PONDS .❑ i hereby certify that I have prepared this application and that th'e work will be done in accordance with San Joaquin,-county ordinances, state laws, and rules`and regulations of the San Joaquin Local Health D7itricti" Home owner or licensed agent's signature certifies the following: 1 certify that in the performance ofithe 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- tionlaws of California.." The applicant m call for all fired ' spections. Complete drawing on reverse side. Signed X Title: i!�, Date: I�I�CJ�.r.1 FiR DEPARTMENT USE ONLY Application Accepted by Date Area 61or Grout Inspection by Date Final Inspection by �" r Dat)2� 4 Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED BY OATS PERMIT'NO . + EH 73-241NEV.1/95 EH 11.28 —71