SR0082866_SSNL - Laserfiche WebLink

Home Browse Search

, 1 APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 15 J4 Address G Levee' AZ Ci Y.4Cy n L city ,_— Lot Size PM O%Vner'sName P- t-V0 OwG4 �� C�OtsC7r ff - Address l�t4 _._ Phone Cdntractor IO/r �.-Vdy _Address 4067 Lud /qy�• License No. !If jr9� Phone f TYPE OF WELL/PUMP_ NEW WELL ❑ WELL 900ACE1W"7--{3'),1 •.) DESTRUCTION ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1' -INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia_of Well Casing ID Domestic/PriJetee,,;C, C-Grravf Pack"`"""'Q' rT'acy— - "Type�f Cggllfg Specifications } Cl Public + .A 1{9--Gther F1 Delta Depth of Grout Seel Type of Grout C;. i �. I I Irrigation ,Z::, ,�Approx, Depth I tl Eastern Surface Seal installed by t Repair Work Done ❑ Type — State Work Done i Well Destruction ❑ Wei i Diameter f I i I SeaGngyfulaterial I�top 50'1 �1 Depth i Filler Material (Below 50'1 - O TYPE OF SEPTIC WORK: NEW INSTALLATION i:1 REPAIR 1AODITIONi4 DESTRUCTION I ! INo septic system permitted it public sewer is { i 1 available within 200 feet.) i f I Installation will serve: Residenceh—— Commercial_ Other Number of living units:�� Number of bedrooms .31 h l f Character of soil to a depth of3 feet: i • I 0 ' Waa,"et table depth SEPTIC TANK �4 Type/Mfg 0O � , Capacity f Nos Compartments r + r PKG. TREATMENT PLT, U i A } Method of Disposal Distance to nearest: Well. 70 Fot dation .-n P'operty Une��: LEACHING LINE 9 No.& Length of lines l 2 00 '� f Total length/size FILTER BED ❑ Distance to",nearest: Well S'i? Foun8aaont I Property Line�� v i Y SEEPAGE PITSSize "'`1=%Di#pdit __._ I Number; I d SUMPS ° ' i L� �[�isi�nceTo nWrest: Welt Foundation__ �roperry Line i DISPOSAL PONDS �+�' ]+ s i� +C I { � rg I I hereby certify That I have pralsi-A tfils'�appIkAtion and that the work will be done in accordance with San Joaquin cunty ordinances, state laws, a6,cy rules and regulations of the San Joaquin Local Health Di§trict. I I L 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 9 employ any person in such manner as to becor1te subject to workman's compensation laws of California."Contiactor's hiring or sub-contracting signatu}e ! certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-D t tion laws of California." 4 The applicant must call for all required ins�pbctions. Complete drawing on reverse side. V L- Signed X_ l _ T Title _ Date: IIV' ! ~8- 9 I j :-=,�r_! ' OR IDEPARTMENT USE ONLY I L f Application Accepted by _._ �' Date O Area tt I Pit of Grout Inspection by Date Final Inspection by pie �(J /3 ,�j f Additional Cam .w.1, i 1 f 'ants: C\ 0 Stk 466-6781 ❑ Lodi 369.3621 \❑ Manteca 823-7104 ❑Tracy 635$,785 Applicant-Retu n all copies to. Environmental HeelthPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OATS PERMIT-NO INFO CASH EH 14-24 7HEV.t�M 51 `'� IEH 14$6 r l