SU0012619 - Laserfiche WebLink

Home Browse Search

H ,. 'APPLICATION FOR PERMIT nn SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I O— N AVE. STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 7 $ (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is he eby made to the San Joaquin Local Health District for a permit to construct andror instal{the wcR1"T( jf+fJQEJhis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Hegulations of the San Joaquin Local Health District. 4-&.44-- City /�— Lot Size PM Job Address — — / � �p�y�� /� Owner's Name '01b, �S � "ddress / 'v` �,��y��t,��4 k09 p & fLLN—Phone Contractor i�[�CLL'�" 5 Address©2�_ License No. TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATIONWELL L1 /z�j�L W_&aiYSTEM REPAIR C] OTHER El DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD._. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WEI.L__ PITS_/SUMPS' _} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t - _ Dia.1of Well Casing — AIndustrial. 0 Open Bottom _1 Manteca Dia. of Well Excavation pe6ifications 7 Qomestic/Private _ 1 Type of Casin Gravel Pack G Tracy 91._4 `_ I I Public 11;r I: Other n De1t5t Depth of Grout .. --- Typo of Grout_ I i Irrigation _.Approx. Depth I ' Eastet"n /�n S,11)ace Seal In tolled by 1 �' I' Repair Wor H. `J i� ' \ Stat'a Work�Dlne ��-. p J,Done C7 4 Type of PUMP ;1 1 J Well Destruction U Well Diameter _ Sealing.Material (top 50'•1 t 1 ` f i Depth _._ ) Filler Material IBeiow 50.1 a t TYPE OF SFPTIC WORK: NEW INSTALLATION I I HEf'AIR/ADDITION 1 i DESTRl1CT10N I I (No septic system permuted it pubGesewer is l- --J, 1. `�J \?vailable-vuithin_200,feet.l " Installation will serve: Residence _ Commercial— Other. Number otoliving units: Number of bedrooms ► 1 Water table depth I Character of'soil to a depth ofj3 feet: — t/ } ' f Ca city T No. Compartments �--_p_ T.y ` SEPTIC TANK �a/M9 --- -�—� --- `{t PKG. TREATMENT PLT..CI Method of Di�osal I\? Well Foundation Property Line Distance to nearest: -� LEACHING LINE Cl No. & Length of lines Total length/size- Well FILTER BED Distance to nearest:C7 Foundation _ Property Line — ! SEEPAGE PITS I i Depth _-.. Size Number SUMPS 0 Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS n I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cotiordinances, stat laws, and rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichithis 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 r certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's;compensa- f1 tion laws of California." ` The applica�t �o �req �tio�nsConplete drawing on raver a side. — ��—�itlo: � / 1I r� Date: Signed X _ r FOR DEPARTMENT USE ONLY �pYJ i /iC) Date!' b? 0 G Area o 1 Application Accepted by =_ -- :� f r1 Pit or Grout Inspection by — Date _ Final Inspecwn by Date I Additional Comments: I 1 C Stk 466-6781 L Lodi 369-3621 U Manteca 823-7104 n Tracy 835-6385�_ f Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltnr Ave—P'Q9bs�'2009, Silk., CA�952t]1 I I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ` PERMIT'N0. INFO SS-mss �.EH 13-24 Ir1EV.tinea EH 14 26