SU0003904 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT S N JOAQUIN LOCAL HEALTH DISTRICfo 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 pP V q 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. r Job Address¢f 0D / 4, ®® �JCity�S/J�y�rL� Lot �Size �r��q� PM Owner's Name AU IN � { Address J6 B� �0 7/J Od4wfL "er"C 0A;ne-5/4-1731-,!7 3/ L Q& 7 �Z Conlraclo4+Ul<4YAV,12 /L Address Pe. Y /(P �"�License No. JZYz z�'Phone t' TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 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 LI Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I"1 Public 1-1 Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type or Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material flop 50'1 (•/ � Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Y/ available within 200 feet.) ... Installation will serve: Residence_ Commerpial_ Other Number of living units: III Number ofdroo is Character of soil to a depth of 3 feet- _ �} Water table depth SEPTIC TANK )PI, Type/Mfg _"Capacity " No. Compartments t r PKG. TREATMENT PLT.0 1 / Method of Disposal Distance to nearest: Well N50 Foundation AO Property Line- r LEACHING LINE No. & Length of lines — Totaf length/size FILTER BED 0 Distance to nearest: Well 100 E Foundation , _� Property Line rTr SEEPAGE PITS X Depth Size Number / SUMPS Ll Distance to nearest: Well 252� Foundation p r Property Line DISPOSAL PONDS Il 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 Deltrict. 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: "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 m call for al r uir inspections. Complete drawing on reverse sive _ Signed %------u �` Title: Date, Q FOR DEPARTMENT TMENT USE ONLY �J Application Accepted by42�vDate '� l Area �j'�or Grout Inspection by ate 9 C�� Final Inspection by�- Date�� Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. EN 138E(REV.