SU0010394 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 I 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. I Job Address � 5� � /P� _ City .G.0 Lot Size PM 1 Owner's Name tTO E 13 v Y UFl Address _ __ _ Phone Contractor ^rz/Io/kJ�C�y —Address AWA'�i o" Ui'7 "/g�to license tJo�f�/�_�l Phxfe..__ TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ I A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14 ` DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i i FOU. DATI_N AGRICULTURE WELL OTHER WELL PITSISUMPS = INtENDED USE TYPE OF WELL PROBLEM-AREA "CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravelel P.& ❑Tracy Type of Casing _ Specifications I'I Public n Other '" FI Delta Depth of Grout Seal _ Type of Grout_ I litigation _.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Worcf—Done -1- —Type'of-Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material(top 501 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: -NEW INSTALLATION,01 REPAIR/ADDITION I i DESTRUCTION I i INo septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial_ Other ►.- Number of living units: _.L Number of bedrooms 3 Character of sod to a depth of 3 feet: �A v'v Water table depth ✓J�� SEPTIC TANK 16 Type/Mfg Coity (xy0 PKG. TREATMENT PLT"❑ Method of Disposal 1 r Distance to nearest: Well 1 00 'Foixtdation _ l s Property Littre �✓`� I1 �t F.+ i LEACHING LINE [7 Na. 6 Length of(ares / -- /Ota � __ Total length/size 100' t FILTER BED ,_ ❑, Distance to inearest: Weil 1f7D ' Foundation Property Line�r't SEEPAGE PITS I I Depth /3� __Size 3'9, /5 _ Number A SUMPS A Distance to nearest: WeltL00 t Property Line Foundation _[Y' _ DISPOSAL PONDS ❑ ! I t I hereby certify that I have prepared this appkcation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shad not employ any person in such maturer as to become subject to workman's compensation laws of CaLfornia."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.I shalt employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all required inspections. Complete drawing on reverse side. Signed X _ Title: _ _ Date: S— 9 R DEP RTINENT-USE ONLY --" — Application Accepted by _ Date Pit or Grout Inspection by Data Final tnspeetion by _ Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant - Return all copies to: Environmental Haahh Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 ,1 EE `► IN O AMOUNT DUE AMOUNT REMITTEO CASH RECEIVED 8Y DATE PERMIT'NO. ♦EM rib TREY.rl.51 EM _� �1 .oag6 5- 1;1 - IS t�-Ie --.i.