SU0005179 SSNL - Laserfiche WebLink

Home Browse Search

I 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 ten Joaquin Local Health District for a permit to construct and/or Install the work herein described.Th's application's made in compliance with San Joe It in Cnunty Ordinance No.579 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City—�T'� Lot Size ' PM_ Owner's Name ( -may �2• ' i''y Adtlmss Phone lZoTo �or/�'f�L /10•.�dxsr� ni! ZnEoai let—Z6/ �.�.: Contractor _Atltlress � License No._ Phune TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN'iTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLD.__ PROP. LINE FOUNDA'ION AGRICULTURE WELL OTHER WELL . PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Ex^avation Dia.of Well Casing ^U ❑ Domestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications ! ❑ Public ❑Other ❑Delta Depth of Grout Seal Typo of Grout O 4 ❑ Irrigation �ppinx. Depth ❑Eastern Surface Seal InstalliE.by (� Repair Work Done 0 Type of Pump _ H.P. State Work Done -2 Well Destruction ❑ Well Diameter Sealing Material(top 501 __ t Depth_ Filler Material(Below 501 'y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION o septic system permitted 8 public sewer is a available within 200 feet.) Installation will serve: Residence� Commercial y�2 thea y• f�C'P�F SE-?iiC T4�Y�! O.�L� Number of living units:-� Number of bedrooms l Fr i Character of soil to a depth of 3 feat:- �C�/ _Water table depth —/ �<�_ C//jT CO�!!LT{' Ce aci 2 sc No. Com artments L SEPTIC TANK tl Type/Mfg _. — P ty— p City "i PKG. TPEATMENT PLT.❑ 6, Method of Disposal Distance to nearest: WellFoundation _ Property line 2 LEACHING LINE ❑ No.$Length of lines Total length/size FILTER BED ❑ Distance to neorest: Wel! Foundation Property Lira SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lim _ DISPOSAL PONDS ❑ I hereby certify that I have prepared this.application and that the work will be done in accordance with San Joaquin county ordirgnces,stats Jews, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed of signature certifies the following:"I cortify that in the performance of the work for which this permit is issued,I shall not )� employ any person In such r>a mer as to become subject to workman's compensation laws q!California."Contredor'a hiring c subcontracting signature certi ies the following:"I certify that in Me pedormanee of the work for which this permit is issued,I ahall employ persons subject to workman's compensa- tion laws of California." aIerns The applicant must cr all reqs ad In % .Complete drawing on reverse side. y >1 Signed � _ Title: �9y� d Data: F=ENT ENT USE ONLY �/ APPIICPIien Accepted by —�r��'-/ Date r _� b A\4l - pit or Grout Inspection by Date Final Inspection by -tA•s+ -�•`"''`""'� Date 9'- s rAd 'ona7 Comments: Dqtk 46C-6781 ❑ Lodi 369-3E21 ❑Mentees 823-7100 ❑Tracy 835-M App ant- Return all copies tq:Environmental Health Penult/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk.,CA 95201 CK M PERMIT NO, NiD AMOUNT DUE AMOUNT 3EM11 CASH RECEIVED BY DATE SEH 1aaa laEV.1/lel�O /Ib FN r4La