SU0002651 - Laserfiche WebLink

Home Browse Search

I t 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIREC a YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to cons.....and/or instal the work herein described.This epeicatbn I. Wade in comNlance with San Joaquin Cnmty Ordinance No.5491m sewage�eor No,.0621mor well/pump and the Rules and Regulators oft"Sen Joaquin a. Local Health District n (+'y�'T-`'tom - �F yr-- (� / .lob Address 3So 7-' JI `V` JDF� /4•- .S�af 7✓/J 12X IQs _ ' q City/,E�'/ ALot Slee PP/M C/_._ kipOwners Ill. to �r lvu-4— Address /1 2 s• `F'��r//(///+- Nana Ata.( -ltcr.FOrM1 'Fts Gsq ✓Cpnraclo, Addless y 7J"I"If/ cense No./ 2 � phonPDLie, 7 TYPE OF WELL/PUMP: NEW WELL Ul^ WELL REPLACEMENT ❑ CESTRUCTION PUMP INSTALLATION CA' SYSTEM REPAIR ❑ OTHER ❑ y Into DISTANCE TO NEAREST. SEPTIC TANK SEWEF LINES DISPOSAL FLD._ PROP.LINE _ FOUNCATION AGRICULTURE WELL __OTHER WELL PITS/SULIPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /y 9 Industrial ❑Open It Ci Manteca Dia,of Wall Ea.avafrm ___ Dia.o/Well Casing b ❑Domestic/Private Gavel Pack 11 Tracy Type of Casio e 7 C B—JSIHs:ficatbm t (�iblic I 1 Other I Who leplh of Grout seal Q I I Iii anon -- TYDe of Grout ll 22VAPpms.Depth I I Easton $wtacs Seal Instal4b M ht _ Rapai Wvk Dane ❑ Type of Pump Sr�A__ H.P._I _ state Work Dons_ 1 ` Weil Destruction E3'Wirt Diatnett G Sealing Material Itop 509 Depth _ SCJ Eller Material(Bak.501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I F16-PAIWADOITION I 1 DESTRUCTION I I (No septic system parmmed it Wblie goer is available within 20D teeL) Installation will serve: Residence_ Commercial_- Other Number of living units:_ Number of bedrooms Character of sol w a depth of J feet Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No.Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Procell Lie LEACHING LINE Cl No.&Length of lines Total length/rise_ FILTER BED CI Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Sita_-_.____ Number SUMPS LI Distance to nearest: Well Foundation__ Property Lim DISPOSAL PONDS ❑ no I hereby certify that I have prepared:his application sad that the work wi'I be done in accordance with San Joaquin county ordinances,state bee,amt rules and reBulahons of the San Jauqum Local Health District. Home owner or Iiceeed)ant's sipnatuio unifies the IpXowirg:"1 certify that in the podarrnan.e df tfe work for which this permit b isued,I thin not employ any person' umoor a:to become s.bunt!o workman's compensation laws of California."Contractor's being or c4contrac.ing Mgemncanities the IDA ng:' y that in the To rmaace of work for which this permit is issued.I steel employ pab one subject to workman's companies. two an laws of liner Ttw epdic t ba'/all mqui pl i p on/no arse siCde..y� �) Signed T':le: L-Jn5•J /// N Date: ///r— ` _'L��`J \R DEPARTMENT USE ONLY `' ! Application Accepted by e) pn�,� Oats LL Arora Pit¢Gro..Irapection by 1 99 Ual:o/ ��i-- Final Inslaec.ion by Dau / I� Additional Comments: 0 Ls1Li[(/. (0 to M a 835-6 � ❑S.k t- etur ❑Lodi 36¢3621 a th Parra B27y/Id ❑Tracy A3...85 Ap{Jaunt-fletvm all copies to:F,rnironmentel Health Perai V farvieaa 1601 E.Haeell0 Ave.,P.O.Bds 2009, SIP.,CA g"a:Dl "- a.4�,....i.., kaara,.h.-Cr.r.oftivs LNFO FEE MOUNT DUE AMOUNT REMITTED CA9N BECEMED BY DATE PERMIT No .FM I1N IRfl'.i/efi .�Id' FH 14]e I H7 ��•� L