SU0000086 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT Oct SAN JOAQUIN LOCAL HEALTH DISTRICT ��`ctl�� •� ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466 6781 e✓✓� � /� PERMIT EYP!RES 1 YEAR FROM DATE ISSUED - (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct grid/11'insvtll the work herein described.This eppEcarior t,ca� made in comprawoo with San Joaquin County Ordinance No.549 for savage or No. 1C;2 for well/pump and the Rubs and hcgula'Joru of the Sar'Joaquin Local Health Diatriet Job AdGress241 _��LO1A ,<�. City_I Lot Size PMLw> .r t Owner'sName �QO J ee T a!?o h�_ Address _ Phi Contractor Address License No. r Phone ,rc•1 h, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIVES DISPOSAL FLD. ¢ROP. LINE t _ �J-ham FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CIO• t . - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria: ❑Open Bottom ❑ Manteca Dia.of Well Excavation _ - Well Casing 4 ❑Domestic/Private ❑ Gravel Pads ❑Tracy Type of Casing_ rcatior,z -t+. ❑Public ❑Other ❑ Delta Depth of Grout Seal of C.,ut r A ❑Irrigation Depth ❑Eastern Surface Seal Installed W Repair Work tone ❑ Type of Pump H.P. State Work Done Well Dainuctron ❑ Well Diameter Scaling Material(top 50'1 4 } Depth Filler Material(Below 601 TYPE O�SEPT)t?WORK: NEW INSTALLATION t3REPAIR/ADDinON 1/ DESTRUCTION Li (No septic system permitted if public sewer is Y/ 1� available within 200 feet.) s IrMai willi Residence-Z- Commercial— Oth^r— Number of Eying;nits: I Number of`edrooms__a__ , i CharWer of sod to a depth of 3 feet:_ ��_ Water:atle depth �. SEPTIC TANK d ❑ Type/Mfg _ �_-- Capacity- No. Companrx'ts _ l r' s PKG.T}#EATMENT T.❑ `. Method of D..s}1osas 1 -J Distar:e-tu-neere": Fornttlatall Property Lin, LEACHING UNE• IF-'No.--&Ler;t6 of lines ( Total lengthlstze �d *� FILTER QED ❑ Distance to nearest: Well /00•t Foundation Property Line # 1 f. SEEPAGE OiTs 1 Depth s Size -34, Number _ 1 SUMPS; i .. ❑�Dittance.to-nearest:----"Well}QOr�_-Foundation_. 7, L�t— Prop"Line _'� DISPOSAL7PMDS ❑ r v 1' ' 1 hereby certify that I have ptepared this application and that the wort:will be done in accordance v+ith San Joaquin county ordirrancel stall 19vsa,and rules al regulations of the San Joaquin Loca:Health District. t f ' Home orw or licnt's d ensed ageenature certifies the follgw ng: I certify that in the perfofmance of the work for which this pemut'its uaued,1 aw not employ ditty person in such niwww as to become subject to vrorkman's compensation laws of Califolinii Contractor's hiring or sub-centrocting iQneture certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ penaxs subject to workrhan'a eort,pr�naa tion I+rwS of California." The Ln—w3t call for a�required ktsaections. Complete drawing496 on side. 1 4. _ .- Signed - -'( _TLf1e." ---{-- Date: f-0R DEPA ENT USE ONLY ` t. Appfica.ion Accepted by Date F%ear Grout Inspection by Date :nspection F � Yr Additional Comrt'enu: - `�' _ J D Stk 1815-6781 ❑ Lodi 399-3621 ❑ Manteca EZ-7104 ❑T.•srr 83 [ Applicant-Return all,-pies to:Environmental Health Permh/Services 1601 E. Hazelton Ave., P.O.Box 2OOP,Stk.,CA 95201 1 FEE I _ tNFOAMOUNT DUE AMOUNT REMRTED CASH RECEIVED 8Y DATE P£AMtT•NO. .EN 1124 rr•EV.iS, �� . EN 1616 _.- ...,.• i; - a. ti, yja,'W It