SITE HISTORY - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 ;s 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. Job Address 2g� 17/GtlYi/�2 1-7U�>l DY/Vu City S- (!lt> 8.1 Lot Size PM +1a,,-UC CL_ de las pu/yas Owner's Name I^n Address sari Tl1Q cY CA Pho"1107)4L2 -10 8 ;ll mos- Boor 2ocio� / Contractor PC 2_ plor Gt+o 1i Address Rosey;/l e� � gS�IO License No. �ZG 5 SSS Phone 7/6 3- 713 w EW WELL ID /n1 E//LCL/yR TYPE OF WELL/PUMP: PUMP INS NALLATION F-1U r "SYSTEMCREPAIR C] OTH DESTRUCTIONER X go re�/DIG'S jWd T 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 SPECIFICATIONS _ ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal----Approx. -'O o re o e rl r-"i'le- e c o k Type of Grout rl O r b . vy ,(- ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Soi'l 6,aMP)irr Depth 1 0. O z Filler Material (Below 501 PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is . available within 200 feet.) Installation erve: Residence_ Commercial_ Other t Number of living unit Number of bedrooms Character of soil to a depth of 3 Water a depth SEPTIC TANK ❑ Type/Mfg Capacity o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well d Property Line LEACHING LINE ❑ No. & Len iines a1 length/size FILTER BED ❑ ance to nearest: Well Foundation Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DtSrOSAL ❑ 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, d 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 California." The appli ; ured ons. Complete drawing reverse sid u Signed A, Title: Date: - F A f y Application Accepted by. Date 5—�f I7�Area Pit or Grout Inspec' n by Date �� Final Inspection by Date Additional Comm / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT;DUEAMOUNT REMITTED C RECEIVED BY DATE PE7RMIT'NO. a EH13-21(REY.t/85) .Jc �S� OO V� / �l �S /-��a EH 11.28 4`� ' i l lG