SU0002167 SSNL - Laserfiche WebLink

Home Browse Search

}?L,r AF3i i.� . � + � �'� a �,w°'fir -�J"�.0 '�y'wia�`s�•v7,ayt�a �"�,.�. OP En... Tp•jG �,�,..-i ` J. S. I I y 3 s 7 sy ti t d 5 E r% tt; r2 t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .`i '.4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED rJ� (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.649 for sewage or No.1852 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. . Job Addie,: „4 4/3AT_X A4f' lL city-i.P G Y— Lot'sze d�.e%1CF PM Owners NarmZQ0J9&& �� Address Phone .,'Contractors Name License No. VCX--3Y:Z _ Phone �. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT5lSUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 1 ❑Industrial ❑Open Bottom ❑ Manteca Dia,of Well Excavation Dia.of Well Casing ❑Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications ❑Public" ❑Other r. ❑Delta " Depth of Grout Seal Type of Grout` +` v t .0 Irrkiedon ---Approx. Depth ❑ Eastern Surface Seal Installed by r. Repair Work Done ❑ Type of.Pump" H.P. State Worst Done Wall DasirucWn" ❑ Well DiameterSealing Material[top 501 - Depth Filler Material{Below 50'1- ,TYPE OF'SEPTIC.WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION❑ Wo septic syr tern permitted if pu r is yy available wit'dn 20O feet.) Installation wlll serve:..Residence Z-Commercial_ Other Number" t Irving units:_�. Number of�raoms 3 r L<. Character of soil to i dept h,of 3 feet. yyl ater table SEPTIC TANK ❑` Typ./Mfg 1"f P.G'/ t'•�/ Capacity"�70L+ No.Compartments t PKG TREATMENT PL's.!7 , - I Met.od of Disposal sL]" Distance to nearest: Well Pro Line /A O ^ .e!Le�_ Foundation /d Property �- iLEACHING LINE L. No.&Length of linea ,� - O _w-Total length/size FILTER BED " ❑' .Distance to nearest: 'Well Foundation_.40 Property Line 1�e 'k ,. - - , I SEEPAGE PITS ❑ Depth Size Number ° r -SUMPS -" ❑ Distance to nearest: Well 'Foundation -- –Property Lino DISPOSAL PONDS ❑ ' 1 heroby,certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and ' ;nubs and.regOations 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 s""! ' „employ any parson In such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature V� certifies the following;"I mortify that in the performance of the work for which this permit is issued,I shall employ persona subject to workman's Gompensa 4 tion saws of California." The appika t WI for all aired inspectiana.Complete drawing on rave fs h'1pr>ed Title: r Dari: DEPARTE16c $E_ QNJY r —"A� s a 3� I Applicatlim Accepted by Oste °Pit or Grout Irxpoctionrrbby �� date Final Inspection by r Additiortat Comments:C,� lrrcr �� – 1. ` ❑Stk 48B-t37e1 ❑Lodi 3B� 7••• ❑Manteca 823-71 ❑Tracy 835-6386 • ' ::Applicant-Rehum aR copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave.,P.O. Box 2009,Stk.,CA 85207 INEFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N4. �^r,', ,F y/r k•A:. �Mj. IN