SU0005047 SSCRPT - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 -aS Telephone (209) 466-6781 DATE ISSUED -aO4 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 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. Job Address ii/, V7i}C/17ONG Subdivision Name Owner's Name '7211 1TNR5- Address _2151*71p Phone Contractor's Name sows License No. 2Sy-34-3 Phone 1W6-96x7 TYPE OF HELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public Cj Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seat F]Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 50') ._ S TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIWADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other ly Number of living units: _ / Number of bedrooms �_Lot size /O Character of soil to a depth of 3 feet: G'Lrs.,/ Water table depth /Eb ,T-IS . SEPTIC TANK 19 Type/Mfg 014L-,-,a tt -�SoNl Capacity I 2 No. Compartments Z PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well --!rb Foundation _f-Z) Property Line LEACHING LINE No. 8 Length of lines Z - $s- Total length/size /70 72C 2 FILTER BED ❑ Distance to nearest: Well Foundation _6_� Property Line SEEPAGE PITS ® Depth Size '; i' Number `L SUMPS U Distance to nearest: Well /'QO Foundation Property Line DISPOSAL PONDS ❑ 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: "1 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!; 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 compensation laws of California." The applicant must ca]l for all require I sp tions. Complete drawin on e. G� Signed Xl�/L%L et-- Title: X-71 R _ Date: FO EPA TMENT USE ONLY Application Accepted by / Area —4— Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by _ Date ,{��-'zZ r 7 ❑ Manteca 823-7104 Final Inspection by �7yh Dates ❑ Tracy 835-6385 Applicant - Return all copies to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO - EH 13-24 REV. 10/82 10/82 500