SR0081401 SSNL - Laserfiche WebLink

Home Browse Search

4 APPLICATION FOR PERMIT f� r SAN JOAQUIN LOCAL HEALTH DISTRICT " 1 1 1601 E. HAZEL i ON AVE- STOCKTON, CA M Telephone (209) 466-6781 t' 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. .- J ah K �iA.r✓P r.. �-WnLt ��? -31 -?– 3 Job Address -_-7 !a»" ` A• _ Cit Lot Size PM Owner's Nam Address Ltd--�2-5 Contract � Address r_` cox License No. I Phone;3 p• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L] I I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ 4 I DISTANCE TO NEAREST_ SEPTIC TANK __. _— SEWER LINES _.__ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial E Open Bottom ❑ Manteca Oia. of Well Excavation Dia. of Well Casing 2 yy ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing __- Specifications W 11 Public ❑ Other j Ll Delta Depth of Grout Seal _W Type of Grout I I Irrigation –_.Aplxox. Deptlhl I Eastern Surface Seal Installed by__,�- Repair Work Done ❑ Type'of Pump — H.P. _ State Work Done _ f Well Destruction ❑ Well Diameter —Sea ling-Material-Itop-507 -- ---Depth-- - -- Filler Material (Below 50 l I TYPE OF SEPTIC WORK: -NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is _ available within 200 feet.) '. Installation will serve: Residence— Commercial_�Other�� ` ' 1 yam Number of living units: _� Number o drop — Character of soil to a depth of 3 feet: 'z �, Water tabie'depth'"�l 0 SEPTIC TANK C�Type/Mfg �* Capacity- apacity �+ No. Compartments PKG. TREATMENT PLT. ❑ , r i7�- Method of Disposal c Distance to nearest: Well Fouhdation O / -_Property Line 5 LEACHING LINE Ll"No. & Length of lines __-_._.10 Total length size SO X f� FILTER BED ❑ Distance to nearest: WeI=50L---Foundation.y 10 Property Lihe,� V SEEPAGE PITS 1+1"Oepth 05' Size umtier_.r+7C j SUMPS. -I Distance to nearest: Well-.. oct_ Foundation .� _.— Property Line •_� DISPOSAL PONDS _I 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 + Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in such manner as to become subject to workman's to`rnpsnsMion laws of California."Contractor's hiringor sub-contracting signature certifies the following: "I certify that in the performance of the work for�which.tFiis•permit is.issued,I shall employ persons subject to workman's oompeasa-. . tion laws of California." 1 Thea iicant st cal! for all ,fired ins � pp inspections. Complete drawing on reverse side. t ys J Signed X—_--_ Title: �•-` Date: nQJr ( FOR DEPARTMENT USE ONLY c � / Application Accepted by Date Ares _ Pit or Grout Inspection by Date__._ Final,Inspection by Additional Comments: E–L,- '3+/'"`"�"t� or ❑ Stk 466-6781 ❑ Lodi 3CA 3621 ❑ Manteca 823-7104 U Tracy 835-6385 f Applicant. Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 INFO 11 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. 2 . I EH 13-24{AEV.1,n�, /J�•__ / 7-3& EH 14-29 1