SU0012617 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT „ 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1-YEAR FROM DATE ISSUED' = (Complete in Triplicate) r ` i,. • r tL, 00r11 `?. .:'. 'yip.\I ai..�.�. i,�,..�'J t. orf •..iw t° "�f '�. Appllcation is hereby made to the San Joaquin Local Health District fora 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. )C. • is t .�� Job Address _ _ a<�� (i 1 Ci Y Lot Size PM It � - Owner's Name �A �' Address � � .�� K/•.G`2G/ Phone 7�7 ContractA L ' Address �.�•_ License Nor, _.-Phone TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION C ` SYSTEM REPAIR ❑ OTHER C ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULNRE.WELL T OTHER_WEL1_ _PJTS/_SUMP_S_—, INTENDED USE TYPE Of:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F Industrial LJ Open Bottom F. Manteca Dia. of Weil Excavation_! Dia. of Well Casing O Domestic/Private O Gravel Pack C Tracy Type of Casing__ Specifications O Public O Other 1 j Delta Depth of Grout Seal ! Type of Grout C Irrigation __Approz. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done +y Well Destruction ❑ Well Diameter Sealing Material (top 501 I S Depth _- Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION •tY REPAIR/ADDITION 7 DESTRUCTION C (No septic system permitted if public sewer is C V available within 200 feet.) Installation will serve: Residence 1� Commercial_ Other + Number of living units: -/— Number of bedroo - Y Character of soil to a depth of 3 feet: -�«" l ++ Water table depth �� ~ SEPTIC TANK ❑ Type/Mfg 1 _ 1 I.iLQ. Capacity./U.- No. Compartments _ PKG. TREATMENT PLT. O r ; 7 f Method of Disposal Distance:to nearest: Well S Foundation .. f a rt, Property.Line L- LEACHING LINE No. & Le;ngth of lines n _- _ Total length/size-/L__� X FILTER BED C Distance,to nearest: Wail 100 Foundation__/O Property Line S _ SEEPAGE PITS LZe"'Depth �S.__Size 3 3 f. _ Number SUMPS C Distance to nearest: Well �5 G, Foundation��- j Property Line _.- DISPOSAL-PONDS -J— ---- — t j 11 c I hereby certify that I have prepared this application and tha�the work will.be,done in accordance with San Joaquin county ordinances,'state laws, and C rules and regulations of the San Joaquin Local Healtl'Distiict: Home owner.-or-Ilcensed-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-sub-contracting 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 alifornia." _The applicantst Gall for all equiredr inspections. Complete drawing on reverse side Signed X _ . - u Title: ��- �� Date: I I - - + � FOR O ARTMENT USE ONLY Application Accepted by ___ _Date Area t or Grout Inspection by Date 1r [� ��ma1 11f9 � 2� � p�ction-by�. "- � Date Additional Comments: Fl Stk 466fi781 C Lodi 369-3621 . ❑'Mantes 8Z3 7104 G Tracy Applicant - Retum all copies to:.Environmental Healit-Permit/Servloes 11601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT t)I�EJ' AMOUNT REMITTED-"� CASH RECEIVED By DATE PERMIT NO. EH 13.24(REV.,S) S) r., EH 1426 Jcs r i