SR0080264 SSNL - Laserfiche WebLink

Home Browse Search

�j j �I APPLICATION FOR PERMIT II SAN JOAQUIN LOCAL bHEALTH DISTRICT tQ . 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 r �j PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED �� r (Complete in Triplicate)• ,. 2 r.�►;n,3lor.l,_ _ r ._.. �: r .�'�£ b�r'1,:.n. .Q I 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 well/pump and the Rules and Regulations'of the San Joaquin Local Health District. ' Job Address City moG Lot Size l�c PM Owner's Name ice,^ Address' T Phone - Contractor SIO Address /{�/ f��L`T�• License Noo_1%Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION ❑,'' r r PUMP INSTALLATION ❑ ��, SYSTEM REPAIR ❑ �� OTHER 1 f l DISTANCE TO NEAREST: SEPTIC TANK SEWER�INE5"'' DISPOSALiFLD. _•PROP. LINE r FOUNDATIDN AGRICULTURE WELL OTHER WELL" ��PITS/SUMPS INTENDED USE -.-TYPE'OF WELL PRO13LEMAIR EA CONSTRUCTION SPECIFICATIONS EJ Industrial ❑ Open rBottom ❑ Manteca Dia, of Well Excavation"" ^r Dia. oi Well Cating EilDomestie/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4�_; Specifications -� -j ❑Public C Other ❑ Delta Depth of Grout Seale r "n,Type of Grout ❑ Irrigation 6 ---Approx. Depth ❑ Eastern Surface Seal Installed by% i' f Repair Work Done C1 Type of Pump H.P. _`State Work Done 1 , n Well besiruction -D Well Diameter _---. _ Sealing Material Itap 50't 5 Depth 1 l�. Filler Material (Below 501 _i r LA TYPE OF SEPTIC:WORK,NdNEW INSTALLATION REPAIR/ADDITaON ❑ DESTRUCTION ❑ (No septic'system'permitted if public sewer is '%,. i Available within 200 feet.) Installation will.serve:-,Residence. Commercial-��• ther-- =-T{-"'' Number of living units:_ r' Number of bedrooms ` Water tablerd J th r Character of soil to a depth oi•3 feet: @P , SEPTIC TANK 1 Type/Mfg f Capacity " r `(Moxd No. Compartments PKG. TREAT;ENT PLT.❑ IUMethod of Disposal ! j Distancen- r'�t�eareAt: Well FoundatioProperty Line y LEACHING LINE " IV. & Length of lines Total Total length/sae I i Foundation Pro rt FILTER BED � � Distance to nearest: Well 31S pe y Line SEEPAGE PITS ❑ ^Depth :Ik t1t` Size �� ""' Number '� t SUMPS El Distance i�to neare§t: WeJI Foundation i Property Line DISPOSAL PONDS'k (- I. , hereby certify that I have prepared this application and that the,work will be done in accordance with San Joaquin county ordinanTs, state laws,and rules and regulations of the San Joaquin Local Health 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 employ any person in such manner as to become`subject to workman's compensation laws of California."Contractors hiring orrsub.gpntracting signature certifies the folbwing:*"I`certify that In the performance of the work for which this permit is issued, I shall employ persons subject to dvb'rkrrian's compensa- tion laws of California." The applicant must call for,all quir4 spectio . Complete drawing on reverse side. /J -,6,, . Signed X /A z Title: _ - _ Dater 6 FOR DEPARTMENT USE ONLY f j. r ='-�.,•,...- -� C�=- v. � ( -tel� � , � r Application Accepted by �I vDate Arel Pit or Grout Inspection by Date. Final Inspection by Date J Additional Comments: N ❑ Stk 466-6781 ❑ Lodi 369-3f121 ❑Manteca 823-7104 ❑ Tracy 835-6385 i Applicant. Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201, f rFO AMOUNT DUE; _ AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. EH 13-24IREV.i!s5i _ 'T^ _ �. 9r - EH 14-29 r -