SU0006466 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) LApplication 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. Job Address Av Z A3 ,E, 1,0& 'TYe,e Rd. City JCSC11[ON Lot Size PM A 1 Owner's Name Address Phone 83 " y1VJ% Contractor ,.49Wn PA' 1 SO* Address IVve, License No. 7/yS�'84/� Phone 45 i" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ LINTENDED 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 f M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_. L I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ` Installation will serve: Residence_L_ Commercial_ Other L Number of living units: _J Number of bedrooms J m Character of soil to a depth of 3 feet: .S�Ne(�+ 6e.�M Water table depth I" SEPTIC TANK Yr Type/Mfg CAs7 CapacityI.YGO No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation VO Property Line ^!S� LEACHING LINE PI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 t SEEPAGE PITS 11 Depth Size Number L SUMPS V Distance to nearest: Well /00' Foundation A&a. Property Line �0 DISPOSAL PONDS ❑ ` 1 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 L 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: "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 required inspections. Complete drawing on reverse side. ( Signed X aiA Title: Date: 1-4- 7- 8�l I FOR DEPART T USE ONLY Application Accepted by ! Date Area LPit or Grout Inspection by Date Final Inspection by Data/z(- Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L INFFE O AMOUNT DUE AMOUNT REMITTED CK RECEIVED DATE PERMIT NO. EH 3-1EH 1�39IREV.t/x51 ':LAliL _4a