SU0005732 SSNL - Laserfiche WebLink

Home Browse Search

— APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. ,.,yA ,� / l �.,/4� ,. — Job Address eQ36 7.3 Fr_ �- -_ city�Wc2Ll SKS PM A� �jr.�.�,, r � 4 Ci Od Lot Size Owner's Name •C�CM`t�ai t rms Address _�J�� C Q S' rCJ.�4'N. Phone J, r p Contractor Address .>, .:�_4 �/ 't _ License No. Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout b. ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50) V v TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_X_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK 19 Type/Mfg �++� C 't l �� No. Compartments .. PKG. TREATMENT PLT. ❑ f y Method of Dispoysal t Distance to nearest: Well Foundation Property Line -' LEACHING LINE k] No. & Length of lines Total length/size � • — FILTER BED ❑ Distance to nearest: Well ' Foundation � Property Line SEEPAGE PITS ❑ Depth Size Number — SUMPS ❑ 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 District. — Home owner or 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 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: "1 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 applicant mus all f r all reQu'red inspections. Complete drawing on reverse side. M J� q �j Signed �.� 5 Title: �,�/Le �y' -1'r{u n,nary Date: /✓-8- 96 FOR DEPARTMENT USE ONLY � Q� Application Accepted by !��J�� //'A[ � /D(a�te /0r -96 Area 06 `� RrorBmttTl p oLby �Oate_�1L�v n(!Fina Irls�ect��nity f -1 Date 7— ti Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED I '*C RECEIVED BY DATE PERMIT NO. INFO 1a-24re.Ev.iia 51 �• oo k 71Fr1 1c�/2 13 EX 1426