SU0003634 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2031 466-67E1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'I - '� Al (Complete in Triplicate) OMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th �i d$ i �(ii�application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th!�,V u tons o t e San Joaquin Local Health District. I� Job Address / / G . L _1 J/ City Lot Size PM + \ ' � / 3 D,9 �f.�OZti c�L.�id.t/ a,.Y'.Phone b Owner'si L Name �ess )- Contractor ��""'"��'t'� Address..L4?�G 4 � _ License Nc1lrP 23 �� PhaneA'I;. TYPE OF WELL/PUMP: NEW WELL (D WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i 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 F-1 Public n Other Cl Delta Depth of Grout.Seat Type of Grout _ 1 1,Irrigation _..Approx. De th 1 1 Eastern Surface Seal Installed by Rpair Work Done C3" Type of Pump H.P. I State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material (top 501 iI Depth Filler Material (Below 50') j TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is " cable within eat.) avec � 200 f ;Installation will serve: Residence Commercial_ Other „Number'of living units: Number of bedrooms 'iCharacter of soil to a depth of 3 feet: Water table depth l t' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal is Distance to nearest. Foundation ? Property Line LEACHING LINE ❑ No. & Length of es Total length/size FILTER SED ❑ Distance to. rest: j Well Foundatio Property Line SEEPAGE PITS I 1 Depth Size Number it SUMPS ❑ 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 Di§trict. 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 ernploy any person in such manner as to becomesubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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 ust call for all required inspections. Complete drawing oe, averse side. 1 Signed X -- �1+_/ Date: F D ARTMENT USE ONLY l .rte � �. A' lication Accept bre ` y� ��"t pP p Y Date Araa Pit or Grout Inspection by H Date Final Inspection by �� ' Date �/4 3 Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369.3621 ❑ Manteca 823.7104 ❑ Tracy 835.6385 Applicant Return all copies to: Environmental Wealth Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 r r INFO AMOUNT,-DUE_.. ,,.AMOUNT REMITTED� CASH" —. ,FRECEIVED BY GATE f ERMl7'NO. 13-24MEV.1/it 51 �J, 14 rl _