SU0003638 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA COPY i4 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. �S S Re r6( A ✓ e— City / �' �'p~ Lot sire PM Job Address !'1 j � r ! ]l] �ra1NA✓ �yN]�ddress S� /�` f� i�� Phone Owner's Name rK„n f1-�P 1"f J ��icen -- HCl il! ' 1 l/ ' ress / /v / /� T�6)t' Lse No. Contractor I TYPE OF WELL/PUMP; ;, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k 'PUMP INSTALLATION 131-j,.3 t� SYSTEM REPAIR 11OTHER ❑ 3 SEWER LINES �•- - ,QISPOSAL FLD. PROP. LINE DISTANCE TO NE EST: SEPTIC TANK _- _ P1 LIMPS-� " AGRICULTURE WELL ii r�''* OTHER WELL 1 ¢ FOUNDATION> - } 1NT>NDED USE OF WELL PR08L'EM AREA---CONSTRUCTION'SPE IFI I 1 ❑ Oen Bo ❑ Manteca - --- Dia. df Well ion i Dia. of Well Casing Industrial } p r r , . l 1 �-�i.��. Specifications ❑,Domestic/,Private ❑ Gravel Pack Tracy •=•-- # o Casirig• T of Grout F �q- .: ..�-•I 1 ❑(Public-1,"c. ❑ Other ❑ Delt Qepth of Grou1"5ea1 Type ---Approx. De Eastern ace Seal Installed•by. r ❑irrigation —App Repair Work Done ❑ Type of p H.P. State Work bone Well Destruction ❑ Diameter Sealing Material (top 50'1 Depth Filler Material IBelow 50') ,�1� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑;"REPAIR/ADDITION ❑ DESTRUCTION ❑ avo septiable cystithin m emitted if public sewer is r Installation will serve: Residence ..Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of feet: Water table depth , SEPTIC TANK El pe/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. IJ D tance to nea est: Weil undation Property Line LEACHING LINE ❑ No. & Length of lines ��,,�� tal length/size FILTER BED El Distance to nearest: Well LVSL._� Foundation Property Line SEEPAGE PITS ❑ Depth Size�� umber 2 SUMPS ❑ Distance to near st: aiJ Well 2[?� Foundation�Q��` R+oPeT;Y� e I DISPOSAL PONDS ❑ -Y S" his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an I hereby certify that 1 have prepared t 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 such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in s certifies the following: 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 requi d inspections. Complete drawing on reverse side. z I� Signed X Title: Date: f FOR DEPARTMENT USE ONLY f Area Application Accepted by �v� Date Final Inspection Date it or rout Inspection by Date — I Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 831,6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 i FEE CK RECEIVED BY PATE PERMIT NO. I INFO AMOUNT DUE AMOUNT REMITTED GASH + EH 13.241REV. /05) 99-7 EH 1426