FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

^y lI v APPLICATION FOR PERMIT -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 wort herein.described. Thisepplkation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Rapulations of the San Joaquin Local Health District. � Job Address �n',✓, `'—'1 /W' l\'f " City _ Lot Size PM - Owner's Name K-bl-��1 taJ .l.F"t+A� l,� ' _ Address Mn I&I Contractor ate( tij Address License No.��PhoneTYPE OF WELL/PUMP: NEW WELL,25, WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SY*gtTvEEMRR/E1PPA�AI'R 0 OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE tZSI FOUNDATION AGRICULTURE WELL OTHER WELL + 7"PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION"SPECIFICATIONS\ / - 11 f ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Weil Excavation \ - Dia. of Well Casing Ar i 0 Domestic/Private Gravel Pack 0 Tracy Type of'Casmg L y tS Specifications I Public fl Other 71 Delta Depth of Grout Seal ZQt 1 ! Type of Grout uvktu I I Irrigation Approx. Depth I I Eastern Surface,Seal Installed b� Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter f-Sealing Material (top 501 f iV t Depth � , Filler Material IBelow'501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is - y' - 1 available within 200 feet.) Installation will serve: Residence_ Commercial Other' ` '-.'� Number of living units:.-�-' Number of bedrooms �- Character of soil to/a depth of 3 feet: Water table depth SEPTIC TANK ! % 0 Type/Mfg I Capacity. No. Compartnents - 11 PKG. TREATMENT PLT. 0 ` � Method of Disposal ! Distance to nearest: Well Foundation Property Line LEACHING LINE ` D No. 8 Length of lines Total length/size FILTER BED .El' Distance to nearest: Well Foundation Property Lim SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinaoces, 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 shut not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-ccaltractig signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's compensa- tion laws of C Glom' The eppli nt musto II re inspections. Complete drawing on reverse side. Signed % / Title: Date: ZZ OR DEPARTMENT USE ONLY Applicat n A ep)e y Date / 2r1�� Area Pit or t Inspection by _ Date Final Inspection by Oats Additional Comments: CI Stk 466"6781 0 Lodi 369.3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. I INFO . EM 13-II IaEV. Er Ir-Ze