SU0009625 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 468-6781 1 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. 1662 for well/pomp and the Rules and Regulations of the San Joaquin Local Health District. /� j{—� . Job Address JZ ?00 J` 4172 3 PA city,lmv Lot Size �1 �•��' PM Owner's Name ALL Iikfede Address 7�'!�O 3 aswma ==._.Phone 2. Contract« Address � A License No. Q,¢.t,"Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL'TUREMELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF.WFLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom 0 Manteca Ota. of Web Excavation Dia. of Well Casing L, Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications i Public ❑ OtMr tl Deka Depth of Grout Seal Type Of Grout___.-_._ Inigation —Approx. Depth 1 I Eastern Sudace-Seal Installed by _ Repair Work Done U Type of Pump N.P. - Steve Work pore Well Destruction ❑ Well Diameter Sealing Material (top-ST) - Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION Wb DESTRUCTION I I INo septic system permitted if lic sewer is available within 200 feet-) Installation will serve: Residence_ Commercial Other Q '�- Number of IjVeg units: _ Number of bedrooms Character of soil to a depth of 3 feet: C(Zj3' Water table depth O SEPTIC TANK ❑ Type/Mfg Cap No. Compartments PKG. TREATMENT PLL ❑ I - Method of Disposal Distance to nearest: Well Fo ndetkm Property Lure 1 LEACHING LINE No. & Length of lines - 4Nel Wtgtt1(srte 06 r FILTER BED 6d Distance to neatest: Well��oundetion 45 / Property Lire SEEPAGE PITS 1 1 Depth .Size Number SUMPS L I Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS ❑ I hereby cenity 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 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 subcontracting signature certifies the following: '3 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 cak 1/ required in'sp/ectbrro. Complete drawing on reverse side. Signed X �/� �.G�./ Title: g% _ g 4, _-_ Date: /T /!% PARTMENT USE ONLY - D Application Accepted by L � ! Date ` Area �/e Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Six 466-6781 ❑ Lodi 369-3621 ❑ Marmica .823-7104 ❑ Tracy 8335£385 Applicant - Return all copies m: Environmemal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sot., CA 95201 +s NFO AMOUNT DUE AMOUNT REMITTED DASH RECEIVED aY DATE PERMIT'NO. . EN 1124(REV.I -,, EN a-id ._ -. ...