SR0080264 SSNL - Laserfiche WebLink

Home Browse Search

- APPLICATION FOR PERMIT I' SAN JOAQUIN LOCAL-HEALTH DISTRICT li 1601 E. HAZEL T ON AVE.,-STOCKTON, CA II Telephone (209) 466-6781 ff PERMIT EXPIRES'l YEAR FROM DATE,ISSUED t (Complete in.Triplicate),lp�IQj!, 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. (� 11►7 Job'Address �a+rAG- Q =. City. - P— -Lot Size_ p .r Owner's Name �._ W' Address Phone Contractor (,( _Address _._4L'4 z 1 License Nog:i;l�_ _f Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION O PUMP INSTALLATION f i SYSTEM REPAIR U OTHER f DISTANCE TO NEAREST: SEPTICfTANK SEWER LINES DISPOSAL FLD.. PROP. LINE . FOUNDATION _ AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I \ ❑ Industrial a d Open Bottom U Manteca Dia. of Well Excavation .""". _ t -Dia. of Well Casing n Domestic/Private n Gravel Pack F_ TracT } � Y Type of Casing __ S "v J Public , ( , Specifications J .7 Other :I�° L' Delta ,,Depth of Grout Seal � _ Type of Grout _ l Irrigation _Approx. Depth n Eastern Surface Seal Installed by Repair Work Done 0 Type of,Pump H.P- f ( � State Work Done_ � We11 Destruction t (l Well Diameter _ Sealjng Material,ttop:50'1 .�_- s t Depth 11 Filler Material (Below'50') TYPE OIF'SEPTICIWORK: NEW INSTALLATIO REPAIR/ADDITION FJf DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence/,-- Commercial— Other _,-..,3:'----tom-a--� - .-:,. -� - a.• -- _ kr Number of living units: � Number of bedrooms _ fit ! `J f Character of,soil to a depth of 3 feet'. Water table depth t SEPTIC TANK O Type/Mf 9 — �w—�1 G _ CapBcity_a- No. Compartments �. PKG. TREATMENT PLT. L A r Method of�Disposal + Distance-to nearest: Well _ Foundation'y0� Property Line � . LEACHING LINE ( Ii' No. & Length of lines =LOU Total len9 ih/size_ y FILTER BED D Distance to nearest: Well Foundation' "�` T-Property Line _ 'b SEEPAGE PITS j fl Depth QSize t Number i SUMPSI J rDista'nce to nearest: Well Foundation _ Property Line DISPOSAL PONDS L u 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. I — ! i j r , .. Home owner or licensed agent's signatu•ro 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-compensatibh laws of California." Contractor's hiring or sub-contracting signature certifies the following:'9 certify that in the performance of thelwork for which this.permit is issued, I shall employ persons subject io workman's compensa tion laws of California." 1 � The applicant must call f all r wired inspections. Complete drawing on reverse side. i SignedX _.. -2_r__.__r ��C/ '• / Title: Date: (p FOR DEPARTMENT USE ONLY Application Accepted by . — � Q i _ Date 7- Area f f 1. C!i� Pit or Grout Inspection by _ � _ 'r'•Date Final Inspection by ! Date Additional Comments: < D Stk 466r6781 L Lodi 369-3621 i •C] Manteca 823-7104 ❑ Tracy 8354i3% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE;y INFO AMOUNT DUE»�� AMOUNT REMITTED _ C SH- RECEIVED BY +DATE PERMIT'NO. �. EH 1324(REV.i e Si G�' ,I I - J C� I EH 14.28