SR0080153 SSNL - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (203) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ry (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 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address t t ` City Lot Size ' PM f �- •- y Q �_ Phone � Contractor _ Addiess 1�ar�1[ i0 1 License No. Phone TYPE OF WELL/PUMP: ''`•' NEW WELL' ❑tet;' WELL REPLACEMENT ❑ DESTRUCTION ❑ r 1 t _�' l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G DISTANCE TOO NEAREST: SEPTIC TANK —SEWER LINES _ DISPOSAL FLO. PROP. LINE 7FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS" c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . ❑ Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation J Dia_ of Well Casing ❑. Domestic I Private ❑Gravel,-Pack• T❑Tracy. Type of Casing Specifications �•+ ;1 Public n Other M Delta Depth of Grout Seal Type of Grout _ i 1 Irrigation '`'Approx.,Depth, i I Eastern Surface Sedl Installed by - �./; Repair Work Done ❑ Type o f=Pump,, H.P. Slate Work Done_ _ •_ _, Well Destruction 1-1r'k-We11 Diametei` Sealing Material{ top 50'! /` — lc� _ Depth ler Material(Below-EI TYPE OF SEPTIC WORK-., NEW INSTALLATION 1 1 REPAIR ADDITION"t DESTRUCTION I I (No septic system permitted if public sewer is 0. vailable within 200 feet.) +• Installation will serve: Residence Commercial: �rOther �-r� - ,(� Number of living units: Number ql Wdr o sf' 4 Character of soil to a depth-of-3[eat - Water table depth Q SEPTIC TANK L-)`Typef Mfg � Capacity No. Compartments -PKG..TREATMENT PLT.❑ ...,`' -> Method of Disposal Q? F` Distance to nea7e`sr`. 1%Jeil ,F-0undation-- Property Lute yLEACHING LINE 'Cl No. &'Length of lines + Total length/size T av •-E �FEL'TERt BED`. � ❑ Distaricer'fo nearest: Well Foundation Property Lina � � f SEEPAG-11.PITS IR--Depth _ -Size. 1-2)6 Number. SUMPS--`: - ;j�'Ll-Distahbe to ne'are'st" Well' —L.r Fgundation _�Q%�' Proparty Line r, DISPOSAL PONDS ❑ I hereby certify that i have prepared this,application and that the_wcrk wiVbe done in accords cn a with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health'District.� ♦ r '-t Home owner'or licensed agent's.signature certifies the following:,"certify that in the performance of the work for which this permit is issued, I shall not, employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature " "ce'rtifie`s tlin f5116WIng:1 certify that in the performance of the wdrk for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call fa it re uired inspection:-Complete-drawing-on-raverse-Sid I ` Signed X Title: `r r Date: _ FOR DEPARTMENT USE ONLY { Application Accepted by -1,21 yn " Date a Pi(or Grout Inspection by / Da a /Finan,Inspection by �' ='oats _Z24 7 71 Additional Comments: ❑ Stk_A&6-6781_ 13Lodi 369-3621_ _ C Manteca 823.7184 ❑T 3 %M racy_885 _ �- -----� , —Applicant Return ailcopiesto: Environmental Health Permit/Services 1601 E. Hazelton Ava-, P.O_ Box 201 Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERM17'NO. . EH 13.24 fAEV.,/x5; —7O EH 1`4-26 - a.