FIELD DOCUMENTS - 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 ISSUE h (Complete in Triplicate) JUf+J Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. s 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. 1 / Job Address Ct ugh �' h e!%,k e� City L D 17/1 Lot Size 2 U� r 1r 12// PM f�- Owner's Names rL f7- � - a Address Mks .5L)L)11) C ,h t'f (,ikNN Phone 12L433 /i -471d15 ContractoraityvlI i-rA�-QhU Address��L 5�'• AC_1 ) License No. Phone (L' 444-611_3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-,V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S :J rc Pe �<)ds1A.Y�lE1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Groutt/" hAC ❑ 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 50') V' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.I 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 ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number S SUMPS ❑ 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 issued, I shall not >VF employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cert-dies 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 applic'n must call for all req ire spections. Complete drawing on reverse side. �/ Signed TLA Title: �X [� q i1 / �((L,.('/�%%�I-OlJ rl 1lr1f%!///'lD"ate: �FOR �DEPAq E T USE ONLY Applicatipn Acce ed ^� U 'Q��y Date-Z Area Pit or'G out nspec o y�.� p,�` ��(� L .tFo_ 'Ran-all Inspection by (l D to r Additional Comments: ftW41—W`4.0 CnU tj -cti.f I'y1.r•� \�,SC� -t-a.u.�JW-rvv�'^�� Sof 4'7 . © � P b ❑ Stk 466-6781 ❑ Lodi 369-3621 v ❑ Manteca 823-7104 cUrracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NEH 13-24 O. * EH 147tl IflEV.1ie51 S CJ ��-7/. _7j