84-1121 - Laserfiche WebLink

Home Browse Search

` APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT yf 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209_) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a Application is hereby made to the San Joaquin Local Heaith 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. 18M for well/pump and the Rules and Regulations of the San Joaquin Local Health District. dd 0 � Job Address �. —iA�'47 /4*n City Lot Size '/ PM Owner's Name 6�9-1y A•HCt/In- Address _ �."Phone ..-t.'� (` ,�, [-.-�.�, p ��....c--,.-�.•.�..-._,:., sus Contractor's Name �J�� / License No. ;[�+8 �� ria Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ tESTRUCTION _D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ...` .� (� ,0 HERS❑ �DIS��INGE TO NEAREST: SEPTIC TANK SEWER L1NE5 DISPOSAL FLD. PROP. LINE 4, !V,�� FOUNDATION AGRICULTURE WELL OTHER WELL �``'PITS/SUMPS IN7END�D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA°Tf0_NS ; F E ❑ Industdust is ❑ Open Bottom ❑ Manteca Dia, of Well Excavation �tDia. of Weq��siii ❑ Domestic/Private, ❑ Gravel Pac ❑ Tracy Type of Casing Specifications � ❑ Public ❑ Other ❑ D Ita Depth of Grout Sea ,T►rpe of Grout i ❑ Irrigation ---Approx. Depth ❑ E gsgtern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump fi H.P. SAte WorVND`one ti �. Well Destruction ❑ Well DiametJ _ Sealing Mat�rich(oto 50'} Depth__ Filler Material"{Belnw50' _.... N< Mme.+..�� ...-N .;._ TYPE OF SEPTIC WORK:. `NEW INST4LLATEDN1❑ EPAIR/ADDITION DESTRUCTION ❑ (No-',',$eptic�$yst&n permitted if public, sewer is � �vailabl'e'within 200 feet.) 1 Installation will serve: , Residence Cour m rcial Other Number of living units: Number of be Kooms � Character of%sq�to a depth of 3 feet: -+ a ar b P � � + SEPTIC TANK Hype/Mfg Capacity _ No. Compartmen I PKG. TREATMENT PLT. C7' Method of peal !J Ar%Z_ l Distance to rie rest• Well Foundation Propert{ Line } LEACHING LINE X No. & Length "mins. To al-length/size. " 1 i f FILTER BED El Distance Y� Hearse Well_ Foundation _ roperty Lme t SEEPAGE PITS ❑ Depth Size Nymber _AS� UMPS .r Distance to nearest• Well Foundation & Property Line DISPOSAL PONDS ❑ I hereby certify thati hav4jkrepjred4his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aid rules and regulation of the San Jo�aqui Local Health District. , Home owner or licensed agent's signatu ce?�ifie the following: "I certify that in the performance of the work for which this peirmit is issued, I shall n t� i employ any person i such manner as to bec¢me subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 4� certifies the followin :"I certify that in t pe fo mance of the work for which this permit is issued,I shall employ persons"s 15ject4b orkman's compens tion laws of Califor i The applicant must al or all require i s io s. Complete drawing on revTSid {{ 1, �•�. �- �q��',,. y Signed Title. Date:54 , w FOR DEPARTMENT USE ONLY t Application Accepted by 121 1 IDate Area Pit or Grout Inspection by p Date Final Inspection b Date � L Additional Comments: ❑ Stk 466-6781 Q Lodi-369-3621 ❑ antece 82.3-7104 ❑ Tracy �ffi fi31�3y57�.,U, Applicant- Return all copies to: Envir nmohtal Healt Permit/Services 1501 E. Hazelton Ave., Y. . Box 2009, Stk., CA 95201 ; FEE. AMOUNT D E" AMOkJNT MITTED �C�KS RECElVED;�$. DATE` PERMIT'NO.INFO H i EH 1324/REV.101931 .,��5:`_"1 .z '^•/'l !►'-,..,.n.,-w«.-�--.M— ,.,.�..... 4-28-- + ,,, .,,.- / ✓ I��Z -