SU0004637 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {2491 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 �� C, Q I I�a(implete in Triplicate) J A /f Application is he+e y made to the San Joa +n LocaHealth 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-yJ9AY]LJT710 ES7751- „_S /iupt-&L /VC 7�>-3399-01 Job Address T Jl�lLM '9�- iV�ST City Pti/✓ Loi Size PM / /� 3� Phone L 7 f-V Address AO' X G Owner's Name :�'/V ,D k— ��L- 9C1, j"j0-V0Z_L41_1Y Contractor. T7Q_/h Pgitgdress f-aZ6 License No.S12-LAD Phone_9/8"13� L � A TYPE OF WELL/PUMP: . NEW WELL L3 WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K- 67risr zuD,.i.s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /©! 7b LS t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _j6 1, 'QJJ9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Ta .�e ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. ofgel�i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f`1 Public ❑ Other CI Delta Depth of Grout Seal Type of Grout. .. E I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - - fi-" � Repair Work Done ❑ Type of Pump H.P. State Work Done _ s2 e. �W�71 , Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material IBelow 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is !! available within 200 feet.) Installation will serve: Residence_ Commercial— Other VI Number of living units: Number of bedrooms 0 Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property line G DISPOSAL PONDS Cl 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 DFstrict. 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- tion laws of California." The applicant Rust call for II required inspections. Complete drawing on reverse side. Signed X �+ w �, Title: � o� &7 Data: — ! '!,D FO EPARTMENT USE ONLY .. Application Accepted by Date �~ Q Area er C9 Pit or Grout Inspection by Date Final Inspection by Date f�4 Additional Comments: .: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-M5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO + EH13,24 MEV.I/ EH 14-M 1