SU0010648 - 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 TYEAR 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. 'j/7�y1 ./yr.� Job Address CQ 0 -7 r ��bY� '" �� City /1""' Lot Size /' 7 7 ie PM Y—�� OL 4-ou/S�frti �)11fieAddress31� All C Sp✓irKrs �7a Phone 95-1)0 9 Owner's Name �r—i V46.-.G tyoa Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER ❑ 1. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDAT16N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications 7 Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _ —Approx. Depth I 1 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 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INST;LLATIb REPAIR)ADDITION I I DESTRUCTION I I (No septic system 20 permitted it public sewer is Installation will some: Residence Commercial_70that Number of living units: I Number of bedrooms V 1 Character of soil to a depth of 3 feet:: ae Water table depth g�� LYP�2.. Capacity No. Compartments SEPTIC TANK Type Mt PKG. TREATMENT PLT.❑ � Lia1n�i° °' Prods Method of Disposal Distance to nearest: Well Foundation Property Line r rr LEACHING LINE br No. & Length of lines _ e0.. Total length/size "' FILTER BED ❑ Distance to nearest: Well Foundation - Property Line 1 SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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 applicant#at call for all req u d inspections. Complete drawing on reverse side. r Signed Title: Date: c�—T,/� (\\\1FOR DEPARTMENT USE ONLY Application Accepted by n t�,� �j111 Date �'-� U v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 . O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health_Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I It 11CASH RECEIVED BY DATE PERMITNO. INFO ER 1124 IREV.rrx51 ��rVV �C_.Il �a ✓ -�O ��+'"'�