SU0000031 SSNL - Laserfiche WebLink

Home Browse Search

f ,r { APPIJCATION FOR PERMIT SAV JOtQUIN LOCAL HEALTH DISTP,ICT ,r 1601 E. AZE1,ON AVE., STOCKTON, CA 1-I Telephone {209) 466 6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �{ ~(Complete in Triplicate) 1 Application is hereby made to the San JOEquin Local Health District for a permit to construct and!or install the work herein dwcriUed.This application is r•�de In compliance with San,oaquin County Ordinance Na.549 for sewage or No.1862 for wellJpump and the Rules and Regulations of the San Joaquin Locrrl Health Dis9ict. z G PM yy t Job Address —. J�-l ".__ +—� 2-- Ciry Lot Sire i• '� '{ .l-- Address �?StiJ-�Jy Phone Owner's�:ame C�ntractor�7— ad. �c -T� License No�r�S! Phone _ TYPE OF WELLIPUMP' NEW WELL 'w} WELL REPLACEMENT L] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ 3 DISPOSAL FLO.DISTANCE TO NEAREST: SEPTIC TANK __. SEWER LINES PROP. LINE FOUNDATION _ AGRICULTURE WELL _ OTHER WELL INPITSlSUMPS ( TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --- �� Dia.of y;+t:t:wa�ra ❑ Industrial ❑ Op„n Bottom r,Manteca Dia. of Well Excavation Specifications ❑ pomestici Private C] Gravel F'nck 11 Tracy Type of Casing-- j' ' ❑ Other C Delta Depth of Grout Seat _ Type of Grout.^ _ Q A ❑ Public ❑ Irrigation Ii ,i --APprox. Depth ❑ Eastern Surface Seal installed by y iDannH P: State Work Done V Repair Work i [IType of Pump � Well Destrucbon' © Well Diameter Sealing Material(top 501 61 ! Depth Filler Material(Below 50'1 l j TYPE OF SEPTIC WORK: NEW INSTALLATION'2, REPAIR/ADDITION DESTRUCTION D INo septic sh n 2D0 permitted if pubs sewer is avai '! Installation will serve: Residence Commercial_ Other i Number of,living units: Number of bedrooms _ �JJf/ �_/✓�i Water table depth=j Character of soil to a depth of 3 feet: No. Compartments j SEPTIC TANK ❑' Type/Mfg Capacity__ 1` I PKG.TREATMENT PLT.❑ Method of Disposal (C Ci Distance to nearest: Well Foundation Property Line t T, ` 71- Total j i length/size LEACHING LINE wG� No. &bength of fines _.� F7� 1�f r perry a FILTER SED.. }' Distance to nearest: Well Foundation Pro Line_ 3C F _ �► j P.-umber SEEPAGE PITS ,: 0 Depth — Size f ❑ Distance to nearest: Well_ Foundation _ Property Line SUMPS y DISPOSAL FONDS G ! C I } I heiehy Certify that I have prepared this applicatio,,.nd that the work wilt be done in accordance with San'Joaquin county ord!nancas,state saws,end 'r regulations of the Sa rules and n Joaquin Local Health District. 1 's signature certifies the oltowing:•11 certify that in the performance oe the work for which this permit is Issued,1 shall not Hama owner;or licensed agent $ of California.”Comractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compensation laws certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's tompenaa- tion laws rr rulifornia." The applicant must call r all r !red i tions. Complete drawing on reverse side. �� Title: Date- Signed ate Signed)L�• i FOR L EPARTMENT USE ONLY 4 9- f pate Area / Application Accepted by ,/ L1 Jn. _ Date _ Final Inspection by Date Pit or Grout'Inspection by Additional Comments: - i ❑Stk 466-6781 ❑Lodi 369-30-1 ,i anteca 823-7104 ❑Trp:y ffiCr6385 t Applicant-Return all capias to�Environmental Hea1t PermitlSorvices 1601 E. Hazelton Ave., P.O.Box 2009, Stk.,CA 95201 $, Ka � ' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE FEAMR'NO. E INFO .EH tszz tpEv.r; si �.�1C f EH 542A - � j L i