COMPLIANCE INFO_FILE 6 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL 14EAI DISICT, 0 Py 1601 E. HAZELTON AVE., STOCKTON, v Telephone 12091 466.6781 NL �1 1N�) PERMIT_ EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cl ``,n y� lic Application is herehy maM to the San Joaquin Local Health[)strict for a permit to construct and 7or,4r'' 'thd K�,ein described. This appation is made,n compliance wu .th San Ioaj .n Crmd nty Or ❑,ance No 549 for sewage or No. 1862 for well/pump and theT7ules and Regulations o1 the San Joaquin Local Health D,stn(1 S X20 E, Yr7t �-r/�/:��ttq L� �- Joh Andress OHS`Vlvvs Pt.s.�n(i__MA;,�'T�¢►ns�.1f�.1�,rd City_1Kf�a'1.�.� '.koof Sire �PM�/_�� Owner's Name�DtwT�vatM �i•t,� i�,TVp-,!1rddress 0.19, _MPU& p�L`JT4 PhoneL7��ZD�S� � Addresc � 5+ , Contractor _ Q..._ Q•__ llwose No.No. At> >Phon _1lt)��-93 TYPE OF WEL 'PUMP NE WELL PLACEMENT 1 1 DESTRUCTION I1 PUMP INSTALLATION SYSTEM REPAIR f I OTHER Gr'-- -- '—II j-- 4 DISTANCE TO NEAREST. SEPTIC TANK SEWER LINESDISPOSAL FLD.__—_ PROP. LINE-`'e'/ FOUNDATION AGRICULTURE WELL —__.._. OTHER WELL PITS/SUMPS tNTENDFD USF. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ V Irnluatn,�i , Open Rottom I Manteca Dra of Well Excavation _ Aj__—_._. Die. of Well Casing ! — Oomesuc Pnvau• Travel Pack V/Tracy Type of Casing �j_—� Specifications r 1 Puha r Olhw/1a,,;-6r /y� Delia Depth of Grout Seal Type of G,.t(:*- Io,ijat'oo Appio, Depui V , - Eastern Sutlace Said Installed by Repair Work Doi, Type of Pump _ H P. _ State Work Done — tel—--- Wen Destruction Well D'ameter � Sealing Material Itop 501 Depth .— Filter Material (Below SO') __— TYPE OF SEPTI(; WORK NFW INSTAL L ATION I I REPAIR/ADDIIION I ' DESTRUCTION I I (No septic system permuted if public sewn is available within 200 feet.)Installation will serve Residence ._ .. Commercial ..__ Other _ Number o1 living units: __-_- Number of bedrooms. Character of sod to a depth of 3 feet: — _ deloth _ _--------------__---- —Water abb SEPTIC TANK I 1 Type/Mfg Capacity___ — No. Compartments _ PKG. TREATMENT PLT I I s Distance to merest: Well _. _ Foundation` Proper, LEACHING LINE I 1 No. b Length of lines Total length/sire—'MAR ;939 _ FILTER BFO I I Distance to nearest: Well Foundation _________ Property Lk» v SEEPAGE PITS 1 1 Depth _Sire . -.—____—___ - _. Number. SUMPS I Distance to nearest: Well Foundation _ _ Properry Lina_ DISPOSAL PONDS I I I hereby certify that I have prepared this application and that the work will be dono in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health D3tnct. Home owner or licensed agent's signature cenifies 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 won •n's compensation laws of California."Contractor's hirirq Or sub-co"l ctirg ttiignature certifies the following "I certify that in the performance of the r which this permit is issued,I shag employ persons subject to wOrkfnMt's compenp hon laws of California." The applic nt si call log I r quved inspections. Complete, ,wing on reverse skis. (�S1i� Mit�Y �4 `1e`}�•' T ppTiL`t��n Signed X- L ____ __ __ Title: CO�/wZ— »r+. 1� Date: G_l qAN IOAr)I;IN I.0(-AL FIfAI_TH DISTRICT FOR DEPARTMENT USE ONLY !I.••,•�i iii.�1• l t.lj �1 TIS [DIVISION Application Acceptod by ___—._. .___ _._____ Date._ Pit or Grout Inspection by —-- Dat '3 final Inspection by ��Ly4� Oete Additional Comments' — Stk 4666781 C Lodi 3693621 ❑ Manteca 8237104 G Tracy 835.8385 Applicant - Return all copie.to: Environmental Health Parmit!Services 1601 E. Harelton Ave., P.O. Box 2009, Stk., CA 95201 . FEE AMJUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT NO, INFO -•--- .-- LA ,1 Jt 111!V - r t 3 IJ'�C'� V r'n i H 14,M _