SU0003426 - Laserfiche WebLink

Home Browse Search

5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) IApplication 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 j Local Health District. i. f Job Addres iY� � " �� Cx INN icy City MAA-Aecil Lot Size r y�4 ACIU PM 1 Owner's Name _ f ' &U0(!.S Address Phone I I - _ r Contractor -Ft M CAIZGILL Address +✓S6 L+�D `� 1 1�i License No.2_(I311 P' Phone &2-3 6S a TYPE OF WELL/PUMP: NEW WELL _ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION —SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial - Open Bottom L Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack L Tracy Type of Casing Specifications \ f'l Public' 7 Other i. Delta Depth of Grout Seal Type of Grout 1 1 Irriilation —Approx. Depth 1 Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done n ! Well Destruction L__ Neil Diameter Sealing Material {top 50'1 i Depth Filler Material (Below 501 y fFYP.E-OF,SEPTIC--WORK—NEW.INSTACC ATION_..< REPAIR/ADDITION l I DESTRUCTION ; (No septic system permitted if public sewer is available within 200 feet.)'; Installation will serve: Residence Commercial_ Other ��t+ Number of living units: Number of bdrooms Character of soil to a depth of 3 feet: __ . Water table depth SEPTIC TANK Type/Mfg Pa--cl s, _ Capacity NCO K-t� No. Compartments �J PKG. TREATMENT PLT. W ' t Method of Disposal Distance to nearest: Well 1 Foundation s Property Line LEACHING LINE - No. & Length of lines Total length/size 3 24 ' FILTER BED _ Distance to nearest: Well Foundation Property Line I � SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1E 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 shalt not employ any person in such manner as to-become subject to workman's compensation laws of California_"Contractors 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 The applicant must call for all required inspec ns. Complete drawing on reverse side. Signed X Title: 0�kweL_ Date: ,�' 9-110 OR DEPARTMENT USE ONLY � A Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i O Stk .466-6781 G Lodi 369.3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. EH 13-24 1 i EH 14.26 IR£V.r i n Sr !A 1 , �� \� 1ea� -cc 03