SU0000565 - Laserfiche WebLink

Home Browse Search

. 1 Alta APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE!-TON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal the work hsuein described.T►'s 805 tei 's ; made in compliance with San Joaquin County Ordinance No.649 fa sewage or No. IM2 for well/pump and the Rues and"OVutafone d.ne Saw Jr-':"n Local :.ealth ;strict / l✓/ 40 job Address �% .�_S=-- `"l ChV�r 1— lot Sin 1Q_ s /1 /(rr� Phone hwner's Name A)& 4 V Address ! Conti.cloy C,• Y� , ^� Address .r �/ � � License No.�» 7.1 Pimm . TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT U DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER L7 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 Ll Industrial J Open Bottom ❑Manteca W.of Wel Excavation Dia.of W04 Care" — Cl Domestic/Privr!ro 0 Gravel Pack Ll Tracy Type of Caring-.._ SPKW"two VI Public 1.1 Other F1 Delta Depth of Grout Seal Tye of Grout I I Inrgation __Aptxox. Depth I I Eastern Swlace Seal Installed by Repair Work Done l) Type of Pump H.P. State Work Dona_ Well Destruction (1 Well Diameter Sealing Material Itop 501 _ Depth Filer Material 1601low 5M TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESIRUCTION I I INO septic system pool tteJ if pubbe vww is available within 200 foot.I Installation will serve: Residence ✓ Commercial__ Other Number of living units: ----L Number o1 bedrooms-3 Character of soil to a depth of 3 feet. Water table daOeA SEPTIC TANK L•i' TypeiMfg - CapecNy A?00 Na moll,ants PKG. TREATMENT PLT.1.1O t Method of DWposall - r Distance to nearest: Weer 15 r Foundation y Property Lim-3u } LEACHING LINE Mr` No. A Length of lines 0' Tote ength/sure 22 FILTER BED [1 Distance to nearest: Wal 1 Foundation .S - PMPS t Lim--3D SEEPAGE PITS ILV Depth __ Sin4' r Number �� SUMPS t I Distance to nearest: Wel�0 t Found~ C' Progeny Line ..3p 1 r y. r DISPOSAL PONDS t 1 I hereby certify that I have prepared this.yprication and that the work will be dorm in accordance with San Joaquin county ordinancek sola lows, and - rues and regulations of the San Joaquin Local Health District. ` Home owner or licensed agent's signature certifies the following:"1 certify that in the perti'wmance of the work for w ilhild this permit is tssusd.I than`rot employ any person in such manner as to become subject to workman's compensation laws of California."Contdactoes hiring or subaontractsq aiw—re certifies the following:"I certify that in the performance of the work for which this permit is issued.I shore employ pMfwx sublec't to workmen's eotwpensa- tion laws of California." The applicant must all for all,required inspectbrts. Compete drawing onn rr'ewerse aide. • Signed _ _ Tice: :: eV A)C A Dow: -- FOR DEPARTMENT USE ONLY Application Accepted by _� Data Ane- -------- A a e Fh+M Irnspection by Dser�=c it or Grout Inspection by ,�"��Q/ - dl.14-7 or Additional Comments: ��d S`� `^�r} s'r P-� �T ❑ Stk 466.6781 ❑ Lodi 363.3621 ❑ Manteca 623.7104 C1 T 8364,1Bb Applicant - Return all copies to: Environmental Health PwrNt/Services 1001 E.Hetel:on Ave.. PA.. Bou 2001L Stk..G + (FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERearT ND. . [N is N rete,r••+� ter d^>♦