SU0006597_SSNL - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION 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 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. Jab Address !/ /6/7 Al & M7 rz/�,-1/ t City„22k7 �/Lot Size PM Owner's Name ��!� ma'g,"L -- Address r��v�© /rl//.C.l l iC� Phone — C i n Na. Phone Contractor's Name /�A ce se o /ylG��f' .�4JS �U/frr� L TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ * PUMP INSTALLATION.&�/4&Q'� STEM•REPAIR-❑.-_...-..- -. - -.- .OTHER ❑, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL----L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom ElManteca Ria. of Well Excavation ! Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing, Specifications P0 Public ❑ Other ❑ Delta Depth"of Grout`Seal ! Type of Grout LL! ❑ Irrigation LLpproz. Depth ❑ Eastern '. Surface Seal Installed by r" Repair Work Done ❑ Type of Pump S1-zos H-.P. �2 State Work-bone AL61A -E d2EF4S 77Z ff R Well Destruction ❑ Well Diameter Sealing Material {top 501 " `r/frfY Rk11/ Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -� available within:2001eet.) Installation will serve: Residence_ Commercial_ Other x Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .[Water table depth G SEPTIC TANK ❑ Type/Mfg Capacity ;No. Compartments` PKG. TREATMENT PLT. ❑ 'Method of"Disposal f Distance to nearest: Well Foundation Property Line �} LEACHING LINE El No. & Length of lines Total length/size Lj FILTER BED ❑ Distance to nearest: Well Foundation Property Line r i SEEPAGE PITS d ❑ Depth Size Number I� SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 1, 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."Contractors 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 applicanta I f all re 'r inspections. Complete drawing on reverse side. j Signed)L Title:�(��' � Date: FOR DEPARTMENT USE ONLY Application Accepted by 41 Date Area Ix Z�— Pit or Grout Inspection by Date Final Inspection by �r /r Date Additional Comments: ❑ Stk 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 IFEE AMOUNT DUE AMOUNT REMITTED CASE{ RECEIVED BY DATE PERMIT`NO. INFO tql F+Eli 13-24(FIM 10/831 S, t�� sa, / '—7 -' EH 14-26 t