SU0014620 - Laserfiche WebLink

Home Browse Search

- - APPLICATION FOR PERMIT I �� SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT NO. (?CK Telephone (209) 466-6781 _ — DATE ISSUED�� l� PERMIT EXPIRES I YEAR FROM DATE ISSUED - (Complete in Triplicate), Application. is hereby made to the Sah Joaquin Local Health"District;ifor a permit to construct and/or install the work herein described. This application is made in compliance with Safi Joaquin County Ordinance ✓Noo.;5_49 for sewage or No. 1862 for well/pump and the Rules an1040 Regulations ofsthq San�Joagµ Local Health division Name Si"��,iX n4,,� Job Address -//J r—�i7� �,p�G1/ Owner's Name C..l� Q Address > Q- �" Phone Contractor's NameSQ, its_ License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPED IFICATIONS ❑ industrial [:)Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of well Casing ❑ Public ❑Other ❑Delta _ .Type of Casing Ej irrigation Approx. ❑Eastern . Specifications ❑Cathodic Protection Depth ❑Geophysical _ Depth of Grout Seal ❑Other Type of Grout. Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material. (top 50')' ri Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION R; REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residenck ;Z: Commercial _ Other �1 Number of living units: N{miber 0 bedrooms �3 Lot size Character of soil to a depth of 3 feet:� y - y„yy/�i}y{� Water table depth S SEPTIC TANK ,� Type/Mfg cQ71.c" f Capacity /,TA O No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg '' Capacity Method of Disposal Distance to nearest: Well ,Foundation 1�_ Property Line �JT� 5 LEACHING LINE No. E Length°of lines 3^ 170 0 11jeeZTotal length/size FILTER BED ❑ Dist4nce to nearest Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS U Distance to nearest:. Well Foundation. Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin county ordinances, 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 issuedI shall not employ any person in such manner as to become spblect to workmanb compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that to the performance of the work for which this permit is issued, I shall employ persons-.sub,)ect to workman's compensation laws of California." The applica t ca for Lwq ed-Snp ions. Complete drawing on reverse side, Signed - Title: " Date: D '� OR� RTMENT t1SE ONLYAreaAccepted by f Area QZ ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection py Date ❑ Manteca 823-7104 Final Inspection by Dates s- JgTracy 835-6385 Applicant -,Return all copies'to: Envir ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE MOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE PERMIT 1939 O. INFO Q EN 13-24 REV.,10/82 ,/' �� 14-26