SU0005305 - Laserfiche WebLink

Home Browse Search

f APPLICATION,FOR.PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T.ON AVE., STOCKTON, CA FILE COPY Telephone {209? 466-671. 81 1PERMIT EXPIRES 1 YEAR FROM E)ATErvISSUED:._ ''_ " " (Complete in Triplicate),, Application is hereby made to the San Joaquin Local Health District for a`permit to construct and/or install the work hereiri°de'ikri sd.This application is made:in'compliance with.SaneJoaquin County;Ordinance No.549 for sewage,or,-No.1862 for welt/pump and the Rules-and;Regulatiors'of the San Joaquin Local Health District. W) Job Address PM fy.Jr ;e IQ� City TY,A S! __.Lot Sae z Owner's Name ~AYYY � s'ot, �ua.v3tl. Address -s /'9C _.� Phone ;Contractor's Name 1 -Q,/Vf. Licenrse'N9. Phone ;TYPE: OF WELL/ lVEW WELL ❑ j � WELL REPLACEMENT ❑ DESTRUCTION ❑ i i I`. A.. . PUMP INSTALLATION; ❑ 5YS3TEM REPAIR ❑ r OTHER ❑': :DISTANCE TO NEAREST: SEPTIC.TANK1 . � i SEWER LINES D[SPOS�L FLD. PROP. LINE W , i FOUNDATION AGRICULTURE VYELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONISPECIFICAT30NS j❑ Industrial ` ❑ OpeOBojtorn- 0 Manteca Dia. of Well Excalation Dia. of Well Casing i❑ Domestic/Private ❑ Gravel Pack ? Tracy T i of CasingI l ' _ Specifications yeia "';i -❑ Public Q Other 0 Delta Depth of Grout Seal s. Type of Grout ❑ irrigationj `Approx. Depth ❑ Eastern Surface Sealinstalled by �j `Repair Work Done Cl Type of Pump _ H P!_-.-_.- _ State Work Done Well Destruction ❑ ; Well Diameter I Soiling Materidl (top 51 1 � ` Depth j Filler Material (Below 501 i j7YPE OF SEPTIC WORK: NEW INSTARTIONIJU REPAIR/ADDITION 1❑L.4DEST.UC ]ONS❑ 1Mo septic system permitted if public sewer is available within 200 feet-). i Installation will serve: Residence L Commercial Other Number of living units: f Number of bedrooms -3 fi Character of soil to a depth of 3 feet: a. vwv A` t Water table depth SEPTIC TAN=K ® Type/Alifg 7" Ga Capacity rs� 606 No. Compartments .Z PKG. TREATMENT PLT, ❑ it ! ?� Method of Disposal o Distance to nearest: Well /00 Foundation !�y', Property Line LEACHING LINE 5 No. & Length of lines 3 - 9a I �� Total length/size d i _ FILTER BED ❑ Distance to nearest: Well Fo ndationi Property Line SEEPAGE PITS ❑ Depth Size _ Number k; SUMPS- ❑ Distance to nearest: Well:. /-%0 Foundation -Property Line - DISPOSAL PONDS ,❑ I a I hereby certify that.I have prepared this application and that the work Wil be done in accordance wifh San Joaquin county o6narices, state laws, and ; rules and regulations-of the San Joaquin Local Health District. - ; - dome owner or lipensed agent's signature oertifies,the folio` ing: "I certify that in the performance of the work for which this permit is issued, l shall not employ any perso64- such manner as to become subjecf401workman's;compensation laws of Calif Contractors hiring or#tsub contracting signature 6er#fies the following:"I certify that in the performance of t"work for which this permit is issued,I shall employ persons subject to workman's campensa= tion laws of Califemia."., L .� `.--.r Thea licant mu=st II for all required inspections. Complete drawing on reverse side ' Signed Title:_ -... Data //- y-&FS` l - f FOR DEPARTME USE ONLY € ; Application Accepted by Date, 070_ Area Pit or Grout Inspe=ction b . at Final Inspection by Date/ �Z s _ -Additional Cornrn6nts: ` El 6tk 466-6781; O Lodi 369-36211 -d Manteca 823-7104 ro -0-Tracy 635-6385 is ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009; Stk., CA 95201. ' FET= CK.. _ -. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. _ +-EH-1324{AEV. lid _i01831 EH 14-26