SU0010733 SSNL - Laserfiche WebLink

Home Browse Search

s i! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (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 in r" 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 Di/strict.�L. ,lip ,/�/�-/t �jl %_ n Job Address !o 3 S / ', &" p"l 1�LCi/ti/ y City Lot Size PM f / — Owner's Name � '�' \ \ t Address l O'�"'�� "9 rte. —. ` Phone +'Bontractor- - - _ ress f License'No: ✓- - Phone 1 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE _TYPE OF,WELL—PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications ❑ Other ❑ Delta Depth of Grout Seal Type of Grout { ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Typ6 of Pump I H.P. State Work Done i �Well Destruction ❑ Welh Diameter -----.-LSealing Material (top 50') � { Depth Filler Material 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic Q 61'` f I _ p system permitted 'rf public sewer is ' y `N {} n _� avai ble ithin feed ' Installation will serve: Residence i Commercial_ Other NF��LL-2 i Number of living units:_ Number of bedrooms 1 Character of soil to a depth of 3 feet: '. t - - �. Water t bte depth Q SEPTIC TANK ; 1:1Type/Mfg `"/x t acrty 't No. Compartments PKG. TREATMENT PLT. ❑ li S r , - •^ - 1 Method of Disposal Distance to nearest: °W I Foundation- t Property Line LEACHING LINE ` [Ir—No. &Length of lines' r - 1 9 Total length/size FILTER BED # ❑ Distance to nearest: ell C Fo ndatioo Property Line JV .. C .SEEPAGE PITS ❑ Depth Sizer _ Number -Y _ SUMPS El Distance to nearest: Well bun ion' - Property Line ' -DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application'and that the work will be done in-accordancewithSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heal?h,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 t employ any,person in such manner as to become subject to workman's compensation 6"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 is4sued, I shall employ persons subject to workman s compensa- tion laws of California." iThe apvlica/nymust call 'fo��/yyy all required inspections. Complete drawing on reverse side Signed X rA't/jl'i � _— Title: psi. - -} — 1(f Date d� 1� � FOR PARTMENT USE ONLY—,r ) t p, Applidation Accepted by I (A, w et, O, -=n Date 4a _u 'J Area b _ _ -r � .� Pit or Grout Ing ction b � ®- j pa Y Date Final Inspection b Dat -Additional Comments: i' ❑ Stk 4666781 ❑ Lodi4, 369.3621 ❑ Manteca 823-7104 1 ❑ Tracy 8354M ' Applicant - Return all copies to! Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n l FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT'NO.' ± Hi 1 3.24(REV.1/15)_ 7L,1_0 - l �.- ...+.---..-- l EH 1629 ..--�