SU0002722 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STO CKTON, CA 'telephone (209) 466-6781 t. PL-RMIT EXPIRES 1 YE'A_R FROM f1nTE ISSUED ----_—___..(C^mpleteinTri;.'r:ara) ------------ Application is Iwreby made to the Sar.Joaquin Local Health Distrirr f •a permit to construct and/or Install the work herein described.This applica:inn is made in comptianca 0th San.Joaquin Courtly Ordmanru No,549 for si.wago or No.1902 for and the Rules and Regulations of the San Joag•lin r - Local I•••aldl District. x:r Job Addross17[ o J .7 City Lot Lot Size PM Owner's Nan:l>O�a-q.��ys�1LC'=C iLa 'l1►EE+.'�E+�Address J /.��C. �.L_r_rF,� t,___. Fhone3—?-3---7 � jam' /� / ..-. ,�Q ' Contractor-�.�-�''v I'.0 1T✓�7/AddreS' �.x 1e� __ '�r/�'�-�+�_License M3/LIDJ�__ . TYPE OF VJEL L/PUMP: NEW WELL IJ WELL REPLACEMENT Ll DEbTRUCTION LI .y PUMP INSTALLATION UI REPAIR C OTHER C7 -fix�.•. DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _.. DISPOSAL FLD.-__ PROP. LINE. 4 FOUNDATION AGRICULTURE WELL ____ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 17 Industrial _ Ll Open Bottom Q Manteca Dia.of Well Excavation _ Dia.of Well Cesin9 1_i Dorrestic/Private 1-1 Gravel Pack 0 Tracy Type of Casing__ - Specificat'ons 4 Ci Public f 1 Other f-1 Delta Depth of Grout Seal _ Type of Grout_ A Ii In•ganon ,_—Approx. Dept 1 I!Eastern Surface Seal Installed by Repair Work Done K Type of Pump H.P.�� State Work Dona Weil Destruction IJ Well Diameter Seaing Material(top 50'; Depth Filler Material(Below 50') �s: GA TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR'ADDiTION UESTf1UCTI0N 11 (No septic systmn permitted if public sewer is � a -� available within 200 feet.) C� t�• Y. t-` Installation will-,erve: Resident-t_ Commercial— Other Number of living units:_— Number of bedrooms--- r \Jr� . Character of roil to a depth of 3 feet: _ _. .Water table depth__ ✓r�� J SEPTIC TANK ❑ Type/Mfg ,___. Capacity ._ No. Com{,.•rtments PKG. TREATMENT PLT.[1 Method of Disposal Distance to nearest: Well------- Foundation Property Line \ K LEACHING LINE (-1 No.A Length of lines Torsi FILTER BED 1.1 Distance to nearest: Well___-._ Foundation,.__ Property Line SEEPAGE PITS 11 Depth __ Size �— Number I SUMPS LI Distance to nearest: Well Foundation_._ Property Lina_ t i• ,, DISPOSAL PONDS n I a 1 hereby certify that t havM prepared tl.:s application and that the work will be done in accordance with San Joaquin county ordinances,state taws,and runts end regulations of the San Joaquin Local Health DitluCt. ��• Home owner of licensed agent's signature certifies the following:"I certify that In the parf-mance of the work for which thin permit is issued.I shall not }it employ any person in so,h mannar as to become wb{act to workman's cumpensation laws of California. Conoactai s hiring or wbcontracuny signature ceniflea tht,fallowing:"I ennify that in the performance of the work for which this permit i-issued,I shall employ persons subject to workman's compensa t tion laws of Cabfonia. . The applicant sttcalllllott all required inspectinns.Complete drawing on revs b side. s -� s `"�•' jSigned K_ z /tTitle:_-_ r Date: FOR DEPARTMENT USE ONLY � 1Y\ i tr Zi 1 Application Accepted by _ _—_— Date _ Area 1 Pit or Grout Irspection by _ Date _ Final Inspection bye r-",- Date` t �ti { Additional Comments: ❑Stk 466-6781 O Lodi 369-3621 C Manteca 823.7104 ❑Tracy 635-6365 e+ , Applicant-Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stir.,CA 95201 --- .1 INrO AMOUNT DUE AMOUNT 11EMITTED CK RECEIVED RECEIVED BV DATE PERtAIT'NO. Tit x i f EH EH IIX I ry`ww4hr.^•.-•'+'^"�"'..�rq...n,rw...w..--.......-.. ,,.w.w•wr+..w+.Yr+v.u:.+.L.. ..�... ,..... ... .v... -..�.K Fvi�Y J:i=�trsl .,..... N... Isi_..WWa' ra:int w'( k�f-' f a� t.