SR0082347 SSNL - Laserfiche WebLink

Home Browse Search

APPOCATION FOR PERMIT SAN .JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. Job Address �_C7f' 1- C��G�'• City T r/`)G.�L Lot Size _ PM Owriei s',Name t70�!/t/ �nA fJ i�gir'e5 'Address ' "-- - Phone-837i"�•!`y II1, Contrar.tor__ ILT /k� j S O/Ji" Address 44710A 49L V C C/X7 Avg License No. �' 891 Phone 3p�" TYPE OF WELL/PUMP-. j` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El -^-Y---- -.. UMP INSTALLATION ❑ s SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ •DISPOSAL FLD. PROP. LINE- FOUNDATION AGRICULTURE WELL -OTHER WELL - PITS/SUMPS( INTENDED USE 'I ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private, r'L71 Gravel Pack ❑Tracy Type of Casing-. Specifications l Fl Public p1 Other F1 Delta Depth of Grout Seal _-. Type of Grout I I Irrigation 4*.......... Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done,, 7 Fype of Pump H.P._ State Work Done _Well Destruction -I Well Diameter / Sealing Material (top 501 r Depth Filler Material (Below 50') ------- i TYPE OF SEPTIC WORK: ANEW INSTALLATION REPAIR/ADOITION I I DESTRUCTION I I (No septic system permitted if public sewer is ! I available within 200 feet.) I /ersea4/ Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms.--.--- ,Q-GCLs Lar►�t \�, Character of soil to a depth of 3 feet: -may _ __ Water,table dep th SEPTIC TANK 12! Type/Mfg �?"�° �f�9T _ __— Capacity J'X Q C� No`. Compartments � PKG. TREATMENT PLT. 1 r t Method-of Disposal. t Distance to nearest: Well ��a Foundation Property Line_ 5/✓r_T— ; LEACHING LINE r�r No. & Length of lines J 00 ° _ Total length/size c FILTER BED ❑ Distance to nearest: Welt Foundation Property Line ,4-97 t3 SEEPAGE PITS I I Depth Size Number SUMPS L'. Distance to nearest: Well _ --1 Foundation Property Line DISPOSAL PONDS ❑ 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 "r i rules and regulations of the San Joaquin Local Health District. 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hir(ng 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." II Thea applicant mu ;iIe all required inspections. Complete + pp q pec p to drawing on raver side. +' Signed X _ _- Title: .- Date: ` --STD DEPARTMENT USE ONLY i�� q Application Accepted by �Q.., � •� ?9�,{rot, T__._ __ DataJV-1 " - __.. Aro Pit or Grout Inspection by Data Final Inspection by at Additional Comments: 171 Stk 466-6781 0 Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,_ Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. • II, EH 1&24(REV.ti K5i EH 14.26 L�l� B_10 "'tQ(_ t L{/l VM1 (V II.