SU0005123 SSCRPT - Laserfiche WebLink

Home Browse Search

_ ~ APPLICATION FOR PERMIT "%d 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 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 /%Kam city 49� L - Lot Size �O .�"t+.^6'S PM c Owner's Name A9,2, =xdr_ Z0460 Address :1211l;? �/d �'�yc2�y Phone rr. Contraclor4g ie .ti� ems' Address 117��1_i dfj-j ",�_License NoCz5,�4�2/ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ t. PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER Y' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f Domestic/Private ftGravel Pack ❑ Tracy Type of Casing �e 1;C1T!>vCp Specifications ('1 Public ❑ Other fl Delta Depth of Grout Seal S`A c Type of Grout .. ` 1 ) Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by ZjY/-Cf* _ Repair Work Done ❑ Type of Pump 5{/ a H.P. 11r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ! el r Depth ?/7,0e Filler Material (Below 50'1 '-1+ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) (\ Installation will some: Residence_ Commercial_ Other V Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well 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: "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." Contractors hiring or subcontracting 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 applicants must tccall �for all required inspections. Complete drawing on reverse side. Y— Signed X !�` �� Title: eElll� f/iy/G Fr Date: �7 _ !:Z! _ ` FOR DEPARTMENT USE ONLY G Application Accepted by _ Date - —� / Area Pit or rou Inspection by to - lRnal Inspection by 0Datz Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �\ IN AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT NO. . EH 1}N IREV.vxsl p.S` �O f/ 6 r;2�� ds-p5fL6 , EH 1428