SR0081321 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. ‘C"-->" - k PM — , - l ---, Owner's Name W1-./74°`-- e- 144t_a_c4Irddress ..5"—/3 r- Zeci-,_/), ied Phone 324 s--- 2 . —.... COntractor e-(---"A---i- c...A-44, _ Address --Clie:Y r- Z.,-/-.?,/,V/_ License No. Phone gr.) r-F ,./e-17: ... TYPE OF WELL/PUMP NEW WELL i0 ---..WELL REPLA ENT Li DESTRUCTION E . PUMP IINSTALVitTION 0 SYSTEM. REPAIR Li .,,....- OTHER 0 . ., . , _ . ___.--------- E TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PRQ.B...-LtINE : OUNIDATION AGRICULTURE WELL OTHER WELL-ITSISUMPS ____ INTENDED USE TYPE OF WEL • • • : M AREA CONSTRUCT:ION-SPECIFICATIONS .. ... l.:1 Industrial C Opep Bottom El Manteca I Excavation Dia. of Well Casing 0 Domestic/ Private 0 Grat;/el Pack Ej - Type of Casing Specifications 11 Public n Other Cl Delta Depth of Grout Seal ------'"--------...;type of Grout ....„ ,. . : --...,,,........., I I Irrigation • pprox. Depth t I Eastern Surface Seal Installed by _ Repair Work I t • • 117. Type of Pump H.P. State Work Done Wei Destruction C Well Diameter Sealing Material (top 501 Depth : --Filler7 Maiserial (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION : 1 REPAIR/ADDITION S DESTRUCTION I : (No septic system permitted if public sewer is t , , .' available within 200 feet.) Installation will serve: Residence ___./.---...--Commercial _ I....Other L Number of living units: Z 'iNumber of beclrooms.---' l' Character of soil to a depth of 3 feet: ,-t----------•i',. I Water table depth SEPTIC TANK ZYPeiI Co/S._ --, 1.D.."- "7--- i Capacity_ /2-CS No. Compartments _ .. _,... ...._ PKG. TREATMENT PLT Method of Disposal Distance to nearest: FoundationWF,11.‘..t6c3 -ciTfr- Property Line , LEACHING LINE X No. Length of lines ; Total length/size ,8i , -. FILTER BED 0 Distance to nearest: i: Well .7.---.1'ef -' (216narti-571- Property Line •-•"cl ; ..._... SEEPAGE PITS I 1 Depili Size Number SUMPS -s or,A 1.3 Distance to nearest: ' VV,ell Foundation ' "Property Line . .; ! - - DISPOSAL PONDS ../. E ,t; I hereby certify that I have prepared this application ad 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 Diltrict. Home owner or licensed agent's signature certifies ttle following: "I certify that in the performance of the:werk,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." Centractoes 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." I. The applicant must call fql.all required inspections. Complete drawing on reverse side. Signed X Title: Date: i<-Z FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments: C Stk 466-6781 Li Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Date Area ____3_- -)Date u\ EH 13-24 4REV,Il Si EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CK # RECEIVED BY DATE PERWINO.