SU0001806 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.. STOCKTON. CA PERMIT 40, Telephone (1D9) 466-6781 %it :SSAt9 ,piete Iwo triplicate'/ Application is hereby made to the San Joaquin Local Heaith 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/prep and the Rules and Ree ulations of ,the/San Joaquin Lccal Health District. Job Address et , Jct r r C'N Subdivision Name Owner's Name JJ cs Address ? S r r h Phone Contractor's Name W h F /^ License No. phone TYPE OF WELL/PIMP WORK, NFW WELL r-1 WELL PEPLACtoot otsliaultax[j OOP fNVSLLAfINA ti't1LM PLPAIN ❑ 01rKlt ❑ bgro .E TO aE"Wl fi(A l4 TAM: ;CICO LiNL'. O1SrOSAL FLO. MC►, Lt1K FOUNDATION AGki',ULTURF WELL OTHER WILL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREP CONSTRUCTION SPECIFICATIONS ; Industrial (7jOpen Eottom Manteca Dia. of Well Excavation [j Domestic/Private iJ Gravel Pack Tracy Dia, of well Casing S.J (]Public ❑Other Delta [i Type of Casing Irrigation Approx. Eastern ❑ 7 - Depth Specifications ❑Cathodic Pr"tion oM01 of ro" feel '.,oy+hl0cr) r ,! fit SKr _- *0 iG+irr6 Y� ".mace Saul twaatiw by Ut✓r4r Repair Work Done[3Type of Pump ) 1Y h H.P• State Work Done _ Well Destruction [( Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit pel,witted if public sewer is available within 200 feet.) installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: water table depth SEPTIC TANK [/ 7ype/faf9 Capacity No. cowl toots PKG. TREATMENT PLT, [_J Type/Mfg Capacity Method of Disposal 7� SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE [( No. S Length of lines Total length/size ` FILTER BED Distance to nearest: Well Foundation Property Line a 4 SEEPAGE PiTS Depth Size Number F+` SUMPS 0 Distance to nearest: Well Foundation Property Line "A DISPOSAL PONDS 1 hereby certify that 1 have prepared Lott application and that the work will be done 1n accordance with San Joaquin county .' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r, 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 workmank compensation laws of California. y Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfongnce of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California.' y i The applican must c or requir-d inspections. Complete Owing N n reverse side. 1i Signed X Title: y Date: i nI OR DEPARTMENT USE ONLY Appl cat on Acce by C/" �,__ Aree ❑ Stk 466-6781r Additional Comments: Lodi 369-3621 Pit or Grout inspection by Date Manteca 823-7104 F Final Inspection by — Date 17--1?,Air Tracy 835-6385 ; Applicant - Return all copies .- 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 NO. INFO ILAS o o tom_ 11-27liq'i9s As EM 13-24 REV. 10/82 3LA X10 10/82 500 14-26