SU0010889_SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT �J� /f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 01 `IF" Telephone (209) 466-6781 DATE ISSUED S -7 3 PERMIT EXPIRES I 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 AddressjS�9 t y wy /z o Subdivision Name Owner's Name ,?p pe- CII Address /71 T1 .LEt. ,i brt. r Phone 5P-, Contractor's Name "Isle212 r� License No. 993 ee_4; � i' � .Phone TYPE OF WELL/PUMP WORK: NEW WEEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑(' j�' S \�'� .S ��{ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ ) DISTANCE TO NEAREST; SEPTIC TANK?A l fr SEWER.LINES DISPOSAL FLD. PROP. LI NE, FOUNDATION '6( AGRICULTURE WELL OTHER (JELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r. Industrial ❑Open Bottom Manteca Dia. of Well Excavation —}- Domestic/Private 0 Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [-j Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications Depth❑ Cathodic Protection - Depth of Grout Seat ❑Geophysical ° Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump L H.P. State Work Done Well Destruction ❑ Well Diameter) Sealing Material (top 50') Depth i Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALL&IONIC REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if,public sewer is i available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size T .Character of soil to'a"'xdepth of�3 feet; Water table depth 4'r Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg '�{d..z $ -!r -s P PKC. TREATMENT PLL E] Type)Mfg�. Capacity Method of Oisp sul SEWAGE SYSTEM DistancE to nearest: Well S40 Foundation to Property Line 67p DESTRUCTION r,' e LEACHING LINE No. 8 Length of line Total length/size y FILTER BED ❑ Distance to nearest: Well Da Foundation rty PropeL ne AD SEEPAGE PITS Depth Size Number ❑ SUMPS .•�.-L_ . 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 i t .permit is issued, I shall not employ any person in such manner as to become subject to workmanS 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 lads of California." ' The applicant must call for all required inspections. Complete drawing on side. Date, Date: Signed� i� rL FOR DEPARTM .' CD Stk 466-6781 Application Accepted by '� Area (��O _ . Additional Comments ❑ Lodi 369-3621 "Manteca 823-7104 Pit or Grout Inspection by - Date � � Final Inspection by Date _ ❑ Tracy 635-6385 Applicant - Return all copies t�ronmental Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., L0. 95201 -� FEE I BASE AMOUNT DUE RECEIVED BY DATE Q PERMIT NO. 1 INFO ,t(. �C� U ]0 82 500 - EN 13-24 REV. 10/82 14-26