SU0001201 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT ` i .r= SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAY Telephone (209) 466-8781 C ' O p PERMIT EXPIRES 7 YEAR FROM DATE ISSUEp (Cornplete in Triplicate) h 4 Application Is hereby made to the San Joaquin Local Health District for a permit to construct andfor install the wtlrlt 10 @1n AVo tirx+ibed•Tht.Yippltif(ort ii? t j made In compliance with San Joaquin County Ordnance No.$49 for sewage of No.1862 for wentpump and the.Rubs VW ReguhrOWta of the San Joagtrfn r ^ < r d � Local Health District. Job Address •3��! Q �-�� City Lot Size PM � Aim , fi Owner's Nan"�a � '0 Lr`�1—�--Address _ -? �^e h Contractor L. Address 60 License No. 6 - Ph f , -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' C PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D e lit : t D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES DiSVSAL FLD PROP.LINE r m '; FOUNDATION AGRICULTURE WELL OTHER WELL,_,.,,. _ PIT /SUMPS dQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,y jtF ©hhdustrial ❑Open Bottom ❑Manteca Dia.of Well Excavation .fir of WON Gasi++g W aDamesticlPrrvate CI Gravel Pack ❑Tracy Type of Casing Si:.ttfications M Public C3 Other t�Delia Da�th of Grout Seal Type of Grout ❑Irrigation �__;_Approx. Depth fl Eastern Surface Seel Installed try ,.. ` Repair Work D^ne ❑ Type of Pump ��_-=1�^ H.P. State Work DpnO `h 1 YF t Well Destruc )F ❑ Well Diamete• Sealing Material(top 5)1') „' Depth Filler Material(B low 50'1 e TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public aewer,is i b available within 20)feet 1 f� lnstellationl Residence Commercial_ _. Other I Number of living units; bar of bedrooms Character of soil to a depth of 3 fear.- - Wath bbb depth•^ar s _ ', v SEPTIC TANK n Type/Mfg Capacity_ No.CorrhpMtments, " PG.TREATMENT PLT.0 Method of ;Diaposa! d i 'i 11li1 Distance to nearest:. Welt Foundation "k t,.rjre 4wIC - I �;h LEACHING LINE Q No.&Length of lines Tota!length%stza FILTER BED ❑ Distance to nearest: Wen _ Foundation Property Line SEEPAGE PITS' i7 Depth Sita --- Number ' ` *rriti. <'' " � *z + '� SUMPS a Distance to nearest: Wet! Foundation Property 4. , ,i DISPOSAL PONDS CJ - I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances;state fowl sand �W nrles and regulations of the San Joaquin Local Health District. . �� I,,,:'ski L k-i' Home owner of licensed agent's signature certifies the following:"I certify that In the performance of tha worst for which thiti piin"hlt is wk d,l shah net ' employ any person M such manner as to become subject to workman's compensation fawn of California:'Contractors hiring or sub•con"e tnQ sipaature certifies the following:"I certify that In the performance of the work for which this permit is Issued.I shall employ persotn subject to workmen s eompensa- M. tion laws of California." i The appy I for all requir inspections. Complete drawing on reverse side. Signed X C { -+ - - - -- Title:��c r-4 - Date Z I* Y�• ' ?F FOR DEPARTMENT USE nNLYGs . Application Accepted by Date Aron '0 Pit or Grout Inspection by -� _ Onto Final inspection by w Date Additional Comments: � b : ❑Stk 466.5781 ❑Lodi 36D Wl 0 Manteca 823.7104 FJ Tracy 835.6385 , • � '� ' Applicant-Return all copies to: Environment:.•Health Purmit/Strvices 1601 E. Hareftan Ave., P.O.Box 2409,Stk.;CA 95201 CK a NT AVE AMOUNT REMnTEl} CASH RECEWO BY DATE PF"'T'No. [!1z .., H