SR0084609 - Laserfiche WebLink

Home Browse Search

F APPLICATION FOR PERMIT SAN•JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 9 y /� / /� / -�`f /� Y J .9 J 'fiz z- l O ->!o. c lY// r.. • l ./� l-4 1 1 !T (� GhA Name T� igV144f o0l49A,1.6 Address. 1-1-? ��G` f f-fG �G ... Phone Owner's K CASH l �/AtJg A44` License No.�i� ,. Phone -5% f 14- %K Contractor •CG0ar! ss TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ ;,DESTRUCTION 0.: PUMP INSTALLATION - SYSTEM REPAIR ❑ 1 OTHER ❑ . DISTANCE TO NEAREST: SEPTIC -TANK MAJ'q- SEWER LINES A%'Jf-' DISP-OSA-LiFLO. 4b'Uk PROP. LINE FOUNDATION AGRICULTURE WELL AW-cr— OTHER WELI�_if &/-*- PITS/SUMPS USE. TYPE OF WELL PROBLEM AREA � CONSTRUCTION SPECIFICATIONS _INTENDED _ ❑ Industrial -.. -. f _ Open Bottom - ❑ Manteca •- 8 rr Dia. of Well Excavation /� Dia. of Well Casing Domestic/Private-E Ll Gravel -Pack ElTracy Type of CasinSpecifications Public E Other C�l� Depth of Grout Seal _ h b i!'�� Type o� rout �De;lta I T'Irrigation _ —Approx. Depth I KSstern -� Surface;Seal Installed by ?d1ler- - - Repair Work Done D Type of Pump H. P. _-State Work Done _----. - - Well Destruction D Well Diameter Sealing,Material (top 501_ a = Depth Filler Material (Below 50') - - TYPE OF SEPTIC WORK: NEW. INSTALLATION t-I_REP-AIR.(ADDITION 1.1 DESTRUCTION I I INo•septic system permitted if public sewer is -• 1• \"� available within 200,feet.) Installation• will serve: Residence _ Commercial _ Other Nuifte,r.of living units: Number of bedrooms Character it to a depth of 3 feet: Water table depth .SEPTIC TANK Type/Mfg Capacity � . No. Compartments fPkG. TREATMENT PLT. D, Method of Disposal Distance to nearest: II" -` Foundation Property Line _ LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line ,SEEPAGE PITS I IDepth Size Number,-, SUMPS 6 FI Distance to nearest: Well 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. Home owner or IiGensed agent's signature cert -dies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not 1 . employ any person in such manner as to become subject to workman's compensation Jaws 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, 1 shall employ persons stibiect to.workman's compensa- tion laws of California." P The'applicant rpust call for all required inspections. Complete drawing anriAi6 se side. Signed � � Title: Co -- —L' �' L4==!c Date: _Q ' ,P.7 f R DEPARTMENT USE ONLY j Application Accepted by 0a Date 1- Area Pit or Grout Inspection by Dat& M � Final Inspection b Date f Additional Comments: C.Stk 466-8781 ❑ Lodi 369-3621 C Manteca ,823-7104 0. Tracy 835-6385 Applicant - Return all copies to: Environmental Health'Permit/ Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk.; CA 95201 - t. EH t9.24 (REV. t i n s EH 1929 FEE INFO MOUNT DUE AMOUNT.REMITTED K CASH RECEIVED BY DATE PERMIT NO. --3rJrt t