SR0005788 - 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 comphdnce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump dnd the Rules and Regulations of the San Joaquin Local Health District. Job Address � Ic/9 S t V ra h J /z N L ((Gird City TR�� r Lot Size PM Owner's Name J, r t l r,,o N OPI Address U w� 19 0 S Phone(3 11 pp Tar-r)aKce,jCA 9050'?-Zy2q Contractor V �f� ll� ng� Address IR -0 - &79 5-1 R•o VLAt A License No. LSS 1 96 Phone /6 TYPE OF WELL, PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER I"' So Gori n / S DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP LINE FOUNDATION AGRICULTURE `NELL OTHER WELL --3C' PITS/SUMPS INTENDED USE L7 Industrial F, Domestic,, Private Public Irrnldtion Repair `.York Done Well Destruction r,r�s�i��r.�ryn U Open Bottom ❑ Gravel Pack Other -__ Approx. Depth Type of Pump Well Diameter Depth ;1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS n pbr4 +r 0 it ❑ Manteca Dia. of Well Excavation Dia. j5 Tracy Type of Casing Specifications Cf� Delta Depth of Grout Seal _ Type of Grout Eastern Surface Stijl Instdildd by_V fifi w �R �� e /y 6, H P - State Work Done Sealing Material (top 501 NAT CE,41—,, 7– 6 /,'c Filler Material (Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permuted it public sewer is –� available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation _ LEACHING LINE L1 No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS I I Depth Size SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Water table depth- No. epth_No. Compartments Method of Disposal Property Line Total length/size Property Line Number Ml IN i t Property �R17bAEOUNTY I hereby certify that I have prepared this application and that the work will be done in accordance withE I"10 l�lqgtgy.grt jpAnGeSatal Vaws, and 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 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 subject to workman's compensa- tion laws of California." The applicant must c or all requ inspections. Complete drawing on reverse side. Signed Title: GeO/0 /5 71-7 Date: 3 -2B'- 9' s fOR DEPARTMENT USE ONLY Application Accepted by Date ` / Area Pit or Grout Inspection by Date Final Inspection by ((�� /�, Additional Comments: 3\ V o (J J v ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 EM 13-24 (REV. n 5 EH 14 2e FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT NO. i