SU0010829 - Laserfiche WebLink

Home Browse Search

r 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) 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address [:fZ rT`� Nie/.,.-,, e city D v Lot Size � �7.r3PM Owner's Namek �•G • lr't�"'IC ✓r.Address /? O .Z?0X /3CJ'. Ti,v,-ir for+ Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications A ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material(Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 2DO feet.) Installation will serve: Residence 4_ Commercial_ Other Number of living units: . Number of bedrooms- ( _ Character of soil to a depth of 3 feet: .,nnWater table depth •SEPTIC TANK Type/Mfg "RES, SP padty No. Compartments M � PKG. TREATMENT PLT.❑ " - / Method of Disposal Distance to nearest: Well Foundation Property Una h !_]LEACHING LINE I!X No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 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 -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 subcontracting 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 us1 cijl4fq I required inspections. ple drawing on reverse side. Signed 1 O Title: 0ZbtyL./L 1 Date: 3— 4`S FOR DEPARTMENT USE ONLY Application Accepted by Date _yam Area /_L_ Pit or Grout Inspection by Date Final Inspection by Date-3-r'8J Additional Comments ❑ Stk 4666781 ❑ L 1 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8358385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. /�Of t e +EH 1324(aEV.1/as) t,� EN 7426 -7•J v` O� ��\