SU0008199 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT O D i SAN JOAQUIN LOCAL HEALTH DISTRICT 0� € 1601 E. HAZELTON AVE., STOCKTON, CA �•�/ r Telephone (209) 466-6781 tPERMIT EXPIRES 1-YEAR FROM DATE ISSUED a (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. "' + 1 Job Address 77 —Cl Lot Size b PM Owner's Name N C�3 (� 7� ( 1 AL?� 1 �� 1 T - - Phop�i Contra r-? �M LS3�- d 1 , • �' e No� 2Z.C-3F'han;7,4PC/ TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -" DISTXN'CE TO-NENAEi T7'SEI'TIC-TANK` -""''9�V- EFrC1- ES" � �' 'I?I5POS74L`FLD:"' "'" �PA"bls'rLiNF w FOUNDATION AGRICULTURE WELL .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial QC EIri%n Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing C4`pen+wic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L Specifications f I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout _ i4-fi afion —.Approx. Depth I A Eastern urrface Seat Installed by Repair Work Done ❑ Type of PumpSC&L2 H.P. t_ State Work Done_ Weil Destruction ❑ Well Diameters Sealing Material(top 50') Depth' Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I ) DESTRUCTION i I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence -` Commercial _ Other Number of living units: Numher of bedrooms { Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypelMfgt Capacity" No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina i i I LEACHING LINE ❑ No. &Length of lines Total length/size FILTER HED ❑ Distance 1Q nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number _ - _ -��SUMPS'=� .. Ll� Distancb to neere9i��-"^"Well"�•� '"'fouistlaiibn""� '"' """"Pidiye`riy"-Lina 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 pertormance of the work for which this permit is issued. i shall not I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 applicant must call for all squired inspections. Complete drawing on reverse side. t Signed K Titter Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area (71 vaM,6w1 c, LAr s Pit or Grout Inspection by Date l� 7 Final Inspection by < � Data= c w X22. +'.G t•!/!" , Additional'Comments: i ❑ Stk 466-6781 ❑"Lodi 3WJG21 ❑ Manteca 823-7104 ❑Tr&V 835-6985 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTEt) C H RECEIVED BY DATE PERMIT-NO. 1 f � EH14-241nEV.r/n5Y //� / �_ �• EH 14.26 +r V-� / D� J •� r