SU0004722 SSNL - Laserfiche WebLink

Home Browse Search

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 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. O /-0 n'cres Job Address IY1'SL1� 5eita/NQY Rel. City �sCA LbN Lot Size PM Owner's Namee C, r5 w/9L�L�Y Address IBj J/ scld Alex Phone Contractor kyrbM V SOY Address A00A �R� 4ym, License No.0V BW Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ti 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 ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 /(1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONK DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: —L Number of bedrooms Character of soil to a depth of 3 feet: C sA'do�.Y �^O�/V/ 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. & Length of lines A — VG Total length/size �a FILTER BED ❑ Distance to nearest: Well 1470" ' Foundation .3'n Property Line 3z�' SEEPAGE PITS 1 I Depth ArI Size y'X f Z Number X SUMPS A Distance to nearest: Well ✓� Foundation Property Line 3a 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 D3trict. 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 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 applicant mu t call for all required inspections. Complete drawing on reverse side. Signed Title: �7�(Date: y`�3�91 FOR DEPARTMENT USE ONLY �'I �' y� Application Accepted by Date Area /� r Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 364-362t -❑ Mantels 823-7104 ❑ Tray 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'EE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y DATE PERMIT'NO. NCASH e cu 1124(REV.,,xst r \ l/ / i r-(•� 31.3 /I /r—. 7. -i• -L+ 11—IZ03