SU0010000 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR 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. 7 c ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules `dzhFYRRp�g4.aa "dons of the San Joacqt1uin Local Health District. Job Address '�J] WO.a+41w'�� Rd Subdivision Name inOhP' Owner's Name USS TUY3(Z 60 �.7 Y1Qi%Ce. Address N- na,eVA1 P,44P,44Ln.>,aea �'n Phone t� SRI 3237 Contractor's Name License No. . Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION�) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing _ ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal _ Geophysical Type of Grout _ ❑Other Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTA16&WN REPAIR/ADDITION ❑ (No septic.tank or seepage pit permitted if public sewer is available within 200 feet.) 1 Installation will serve: .Residence Commercial _ Other Number of living units: ,a Number of bedrooms _ 2` Lot size 7..5_1N`Lf CS Character of soil to a depth of 3 feet: may 019ncv - 110 P44w AhU Water table depth >290 or SEPTIC TANK 6j Type/Mfg wM2 4r- Capacity )ate` No. Compartments ? PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well 70D r Foundation /0 Property Line /00'�� DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number 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 District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit i"s issued, I shall not employ any person in such manner as to become subject to workmans compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the wprk for which this permit is issued, I shall employ persons subject to workman's compensation laws of Californiz... The applica must call f al4 required inspections. Complete drawing on irrev��erse side, i Signed X ; Qo hdwQ i>_`.� Title: 1�� r�QZ IL Oate:dWr\ '-L Application 0.cc epted Area P TOM 1IJ��E ONLY Stk 466-6781 h J/salG/l�i+ _ ❑ Additional Comments: [J Lodi 369-3621 Pit or Grout Inspection by �vy1 Date ❑ Manteca 823-7104 Final Inspection by zt�„' Date q 0-is ❑ Tracy 835-6385 Applicant - Return all cops o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. ]NFO B 3 $3- / ^0 EH 13-24 REV. 10/82 to, ' 10/82 500 �,