SU0006349 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q3— 3`�c T Telephone (209) 466-6781 n � DATE ISSUED 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 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 l JRegula /tai ns of the 1San Joaqu^i�n Local//}}}{{{JeA1tIn District. Job Address ,11 /`1y -/Q�il �,I/i� !/�L (C.bt Subdivision Nam Owner's Name -��56l11 Address ,26-7oy OF. �i.1G �Qf�ed Phone �qX Zf Contractor's Name IC4 Q Re L/_ License No. Phone O� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 r PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS to INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing r Public [-I Other ❑Delta Type of Casing Lj Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protgction Depth n Depth of Grout Seal yJ r ❑Geophysical Type of Grout ❑Other Surface Seal 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') l� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms ,� Lot size /00 X )W Character of soil to a dep3 feet: Water table depth SEPTIC TANK Cj Type/Mfg /,QQ-(` 'f" Capacity ISD D No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method ofDisposal SEWAGE SYSTEM Distance to nearest: Well UPI' Foundation Property Line DESTRUCTION ❑ LEACHING LINE - No. 8 Length of lines Total length/size 0 0 FILTER BED ❑ Distance to nearest: Wei IOW/6&I Foundation OVA-161 Property Line SZJI SEEPAGE PITS ❑' Depth Size Number SUMPS +4' Distance to nearest: Well Foundation OV 0� /dOIJJ��Property Line DISPOSAL PONDS CI S " 1 s 170 rez%eA 60/ Wi A a t 4,,,4 d ZS/PjT^A 5)`,e 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmanS 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 compensation laws of California." - The applicant t call g all required inspections. Complete drag on reverse side. Signed K Title: �,�� O VVVVVV � Date: s ZL 83 � r, F DEP TMENT USE ONLY Application cep ed by 4O Area _D4 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date N-Manteca 823-7104 !• Final Inspection by Cf`N -, Date —ro�3�3 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He Permit/Services 1601 E. Hazelton AA., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE P ERMITO.INFO ✓`}1. S / � � •p _ L EH 13-24 REV. 10/82 7/ 10/882 500 14-26