SU0004494 SSCRPT - Laserfiche WebLink

Home Browse Search

0-0 hear LFFrRC>E7 yam oAJ r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091466-6781 L�"M' — Y:a,O r —cnr.wo-✓•r yar-'..r— 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 tmd/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for emerge or No.1%2 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Atltlress �FF dip/. City. rr�� Lot Size G1" M r Owner's Namex)�O to rrtee - �! Atldress 33 y [6"1�.% 1JJ'c.n (7"z, Phone / Contractor VJrf" Address License Nollal Phone 1- TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT IN DESTRUCTION q rear PUMP INSTALLATION lot SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 12 oa I DISPOSAL FEB._PROP.LINE o y FOUNDATION AGRICULTURE WELL =OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS s r ❑Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation O' Dia.of Well Casing 6 f � m Doestk/Private Gravel Pack ❑Tracy Type of Casing Specificad.. 1-1 Public ❑Other ❑Delta Depth of Grout Seal sG' Type of Grout I I Irrigmion —Approx.Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. a- spite Work Done 6" Well Destmaion F2 Well Diameter Sealing Material(top 501 Depth .S'0 ' Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 fel r Installation will serve: Residence— Commercial— Other— Number ther Number of living units _ Number of bedrooms Character of soil to a depth of 3 thio Water table depth SEPTIC TANK ❑ Typal Mfg Capacity No.Components r PKG.TREATMENT PLT.❑ _ Method of Disposal r Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No.6 Length of lines Total length/s(z FILTER BED ❑ Distance to nearest: Well Foundation Propam/Line r SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to hearest: WaPo Foundation Property Lire DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work Mt be done in accordance with San Joaquin county ordinances,state laws,an¢ rules and regulations of Ibe San Joaquin Local Health District. I\ Home..or or licensed agent's signature certifies Me following:"I unify That in Me performance of the work for which this permit 6 issued,I shad ret employ any peraon in such manner as to become subject to workman's compensation laws of CalifomlaJ'Contractor's hiring or sub-conlractmg signature canities the following:"1 cermy that in the perfomwnce of the work for which this permit is issued,I shall employ persons subject to workman's com ramut lion laws of California." The applicant u t cell or all r�9,9u�i/ tl�inspections.Complete drawing on reverse side. �s Signed K� ` ' " '�'"—J 4a.: )')L± � - Date. 6^6—k/ FOR DEPARTMENT USE ONLY Appl: a Accepted by gate A Pit nspedbn b �Dete F TMspettion by Data Additional Coromandel: — ❑Stk 466-6781 ❑Lodi 3693621 ❑Manteca 823-7104V ❑Tracy 8366385 . Applicant-Return all copies to:Environmental Ifulth Pont,it/ ervi e 1 W 7 E.Hasellon Ave.,P.O.Box 2009,Brit..CA 9E201 4/606 AV7W/1/ti✓ ZVM/� ' FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT NO. INFOli CASH r}N lakY.vxnl I EH 1lM 1 r r