SU0005892 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ��// �AN JOAQUIN LOCAL HEALTH DISTRI:.T 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �E ��II V Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the��eEdes � s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the ul ula�7♦111 / he n Joaquin Local Health District. I -' ,(� Job Address � l I Itir�"�� < IC q City d c �. �of Size PM Owner's Name ..��k`yy� (/ Address ��ri.!-_ x✓1X-Ckd Phone Contractor Address r � / License No. Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIFj 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 n ❑ Industrial ❑Open Bottom ❑ Manteca Dia..of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack O Tracy Type of Casing FtL Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by. _ Repair Work Done 1:1Type of Pump � H.P. S� State Work qn Well Destruction El Well Diameter -8- Sealing Material (top 50') Lv` y A Depth S� Filler Material(Below 50') Par _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 1 ) DESTRUCTION t I INo se tic yy6p►�yamm War it d if public sewer is MO table 1119A2lQeI.)^4 Installation will serve: Residence— Commercial— Other C��IRpN(yf�rY l +^Jif Number of living units: Number of bedrooms _ PErwif �l,y l � UCALT __ cul- t7G+1 Character of soil to a depth of 3 feet: Water SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 6 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di3trict. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any perso in uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio In . "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 ia." The applic t call for all req i ed ins C ns. Complete draw'mg on r rse sida. Signed X Title: Me /, AOL-1 Date: FOR DEPARTMENT USE ONLY O Application Accepted by � i✓ Date Area Pit or Grout Inspection by Date Final Inspection by TT Daty��5 Additional Comments: �i G7res„ * -� ElStk 466-6781 ❑ L I 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 NFO FEE AMOO�U AMOUNT-DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT Nro. S EH;4-n(REV.rixa) EN tx-m JLu-r. I—to