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 �a 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. 16 South Cherokee Lodi 207 'x 129 ' N/A Job Address City Lot Size PM Stephhannie "Taffy"weke Address 1045 South Cherokee Phone (209) . 369-4725 Owner's Name Contractor Brown & Caldwell Address 723 S Street, Sacto Cicense No. Phone (916) 444-01; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N A FOUNDATIONAGRICULTURE 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 Specificationa"t-& ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by WepaCil%" E�igr-�119*ype of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TY OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D RUCTION ❑ (No septic system permitted if public se r is available within 200 feet.) Installatio ill serve: Residence_ Commercial_ Other Number of livin its:_ Number of bedrooms Character of soil to a th of 3 feet: Water table depth SEPTIC TANK ❑ /Mfg Capacity No. Compartis PKG. TREATMENT PLT.❑ Method of rsposal Distance t rest: Well Foundation Props ins LEACHING LINE ❑ No. Length of line Total length/ ' e FILTER BED ❑ -stance to nearest: ell Foundation P rty Line SEEPAGEPITS ❑ Depth Size umber SUMPS ❑ Distance to nearest: Well oun::t Property Line DISPOSA NDS ❑ hereby dertify that I have prepared this application and that the work will be one 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applicants m,,usst ccall for all required inspections. Complete drawing on rev rs-e�Jsid/e/. ��yt /, ' '{ C7� Signed X�/rC7- 7L�/1 s(��..._J'✓ Title: 4 L "' 9 6l� Date: 7 �" P SE ONLY Application Accepted b Date — — Pit or Grout Ins do y Date y//—FC&Final Inspection by Date Y Additional Comments. ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ 7fcy 8356385 Applicant Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. INFO EH1a.N IREV.ti n 51 2'l3 3s- vv 145" N O 1-7 O tC,b/07 EH 14711