SU0006074 - 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 compliance with San Joaquin County Ordinance No.509 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District, n / 77 Job Address /1 f r�VVl C!nAl City �0CL/4 ILot Size PM Owner's Name 00Lrt1 CA I�/l Address Q"� Z�J IC�eVVI N' Phone 0(0 ,-:p / S- Arnq( d r1Pz Contractor �T Cn ✓�� Address � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �AC PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER V Soy I 14 bB£�n9 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' I FOUNDATION AGRICULTURE WELL OTHER WELL -'PITS/SUMPS INTENDED USE TYPE OF WELL! PROBkEM AREA CONSTRUCTION SPECIFICATIONS' Industnal'b gyr/Jb(496pan— Bottom ❑ anteca Dia. of Well Excavation �/ 'a. of Well Casing ..�_ I{� ❑ Domestic/Private i ❑ Gravel Pack O?racy Type.of Casing - fications ❑ Public ❑ Other Delta Depth of Grout Seal % cfC1mut Yi ,�n CIA ❑ Irrigation --Approx. Depth j-❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump / H.P. State Work Done ' Well Destruction ❑ Well Diameter f Sealing Material (top 50'1 _ Depth Yf Filler Material (Below 501 + TYPE OF SEPTIC WORK: NEW IN "L TION ❑ REPAIR/ADDITION ❑ DESTRUCTIO ❑ (No septic system permitted if iSublic sewer is / available within 200 feet.) Installation will serve: Resideilfe_ Com ercial_ Other Number of living units: Number of bedr ms Character of soil to a depth of 3 feet: Wate'r table depth SEPTIC TANK ❑ Type/Mfg C acityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well F ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well Fou t�: ��-R1'ogerty Lute SEEPAGE PITS ❑ DepthSize Number SUMPS El Distanceto nearest: We Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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 sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Theappli st call for all uired inspections. Complete drawing on reverse side. (7 Signed Title: f 6 )L �/7 Date: /� 0 b S 0 a ( O DFDARTMENT USE ONLY Application Accepted r Date A _ Pit or Grout In C y — Final Inspection b ate /1 -3 "5�5 Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T cy 83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO eR4 112IBer.1/051E14 M 142