SU0008440 SSNL - Laserfiche WebLink

Home Browse Search

e + APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED �5 (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 application is 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. kkk Job Address 31300 ��4� LAO e— City LLIW4L1'1 Lot Size PM 4 Owner's Name t�''Go Address 7oaej�*L"f' t4"deZ - Phone 4 Cont �[J ' �R Address LIZ/ �7 License No. A7-7–±X—Phone �a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ III PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �- r_ F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � �^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 0 Industrial oi Open Bottom ❑ Manteca Dia. of Weil ExcavationDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cas4g S J Specifications %(rpQJ�G 1Z? l : 11 Public F1Other Cl Delta Depth of Grout Seal Type of Grout 1r4.Irrigation S30r Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumptQI�G H,P. /.36 State Work Done !� Well Destruction ❑ Well Diameter Sealing Material (top 50') C, V Depth Filler Material (Below 501 l) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) III l 1 installation will serve: Residence_ Commercial_ Other �. Number of living units: Number of bedrooms Character of soil to a depth of 3 f t: Water table depth SEPTIC TANK ❑ Type/Mf Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to n rest: Well Foundation Property Line LEACHING LINE ❑ No. 81 Length of 11 es Total length/size, FILTER BED ❑ Distance to nearest: Weil Foundation Property Line FSEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di1trict. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the 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."Contractors 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- tion laws of California." The pplicant m call fo all r uir inspections. Cogtplete drawing on verse side Signed Title: Date: IFFF 1 FOR DEPARTMENT USE ONLY Application Accepted by Date `IQ ` Area Pit or Grout Inspection by Date .Final Inspection by Date — Additional Comments: 13 Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 160t E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT R ITTED CK V RECEIVED BY DATE PERMIT NO. INFO r`v a CAH XX . _ 1.IREV.I R51, 3 J - .IT d,7 `/DLA _nc-,— Z. rr