SU0010839 SSNL - Laserfiche WebLink

Home Browse Search

I APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a• J" (Complete in Triplicate) t4a-oJ Application is hereby made to the San Joaquin Local Health D'Istrict for a pemdt to construct and/or install the work here /descrlbed- This application is made i?compliance-with San Joaquin County Ordinance No.549 for sewage or No.18M for well/pump and the Rules and lations of the San Joaquin Local Health District. - f.''/•• •. y /ud V9` JolA dress MoQr� Lot sae ' pN Owner'sNeeseMlrif FOrM,5 Address -9= 41 4 w&crd �d S� - 7.90 _ —J ne Contractor 1•�` • Address G - License No. t�Q?1,;j Phone .$'I TYPE OF WELL/PUMP: i i NEW WELL DQ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TOr�NEAREST: SEPTIC r.TANK ' 110!9&- SEWER ONES,,. -- DISPOSAL FLO. OAX&-PROP. LINE G - FOUNDAN AGRICULTURE WELL T OTHER WELL PIT74 S/SUMPS �". INTENDED USE TYPE OF WELL I PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 3 ❑Open Bottom 0teca Dia, of Well Excavation Dia.of Well Casing l { ❑ Domestic/Private VGlavel Peck � ❑ Tracy Type of Casing SLG Specifications ❑ Public ❑Other ( ❑ Delta Depth of Grout Seal Type of Grout )(Irrigation 1 —Approx. Depth ❑ Eastern Surface Seal Installed by — (; Repair Work Done ❑ Type of Pump I H.P. - State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material (top gr Depth i { Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted N public sewer is 1 available within 200 feet.) • Installation will serve: Residence—] Commetcial -+ Other Number of living units:_ Number of bedroomskk Character of soil to a depth of 3 feet I Water table depth I SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments i71 PKG. TREATMENT PLT.❑ _ - Method of Disposal ; Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Largth of lines Total length/sae FILTER BED ❑ Distance to nearest: - WellFoundation Pty Line yI l i roperg}. SEEPAGE PITS C3 Depth i I j Size Number � � SUMPS : ❑ Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 `i 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 1 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 employ any person in such manner as to become subject to workman's m r esub- la issued, I shall trot mpensation laws of Calffortda."Contractor's hiring Orsub-eontrectitgsignature 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 co tion laws of California." The epDli nt tial call for all req i d inspections. Complete drawing r arae 'de. / �iSignetl 1 ? Trt1e: . Date: —�-87 ' ( FOR DEPARTMENT ONLY aAPdicetwfi Aecepted by I DateArea 'PitrorG�out Inspection I Date Final Inspection by Data g f Additional Comments: ❑ Stk 466,8781 ❑ Lodi 369.3821 ❑ Manteca 823-7104 ❑Terry- . Applicant; Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 t . ,r• I ' .,. INW AMOUNT WE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. r 1511a-21low.11 / A