SU0006105 SSNL - Laserfiche WebLink

Home Browse Search

r 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 i.07- crF (Complete in Triplicate) 7-C, 197 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address ///SG City F,C Lot Size PM Owner's Name Ai/er Address .2 303 P7104544.1' 2 Uil/ Sj�hone 1,473-19`�— 1.. Contractor FLrrVD Gu cOD Address 7 Al, ADF_&3E/dT License No. Phone 4'4 �7/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications u f"1 Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout--- I rout_ _I I Irrigation __Approx. Depth 1 1 Eastern Surface Seal Installed by _ \` Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �1 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.l Installation will serve: Residence " Commercial_ Other Number of living units: Number of bedrooms -3 Character of soil to a depth of 3 feet: .54 AJZ> Water table depth SEPTIC TANK B Type/Mfg C 0- Capacity__1_7—& O No. Compartments �-- PKG. TREATMENT PLT. O Method of Disposal J / Distance to nearest: Well _5�0 Foundation i0 Property Line /d ' LEACHING LINE 111'-No. & Length of lines — 7U Total length/size FILTER BED ❑ Distance to nearest Well Foundation IJ Property Line X/ r SEEPAGE PITS I I Depth -Size Number SUMPS 0 Distance to nearest: Well 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- r tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X .� f Title: L'!,7!F;& �i. Date: L —y—P7 r FOR DEPARTMENT USE ONLY cam. .. '� - Application Accepted by v � y.,o r_.-.� .� Date -A—lb Area ` Pit or Grout Inspection by Date Final Inspection by rte" !g Date 77/Oif 2 -7a�k �' .� -oto — Additional Comments: tis e,4. z....L- ,j' � T -� � a✓. ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7114 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Sere' 1991 E. Hazeltoo Ave., P.O. Box _ k., CA,952QI,i y. INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ` EH 13-A IREV.rixsi U. L' EH NM