FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT S331AH3S/11WH3d SAN JOAQUIN LOCAL HEALTH DISTRICT Hllf3H '1d�3WoaWAN3 1601 E. HAZEL T ON°AVE., STOCKTON, CA Telephone,(209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUE Q f:4 . (Comple1te In Triplicate) Ithl Application is hereby made,to the San Joaquin Local Health District f ,a permit to construct and/or install erern described.This application is m... or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin er made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health Distric�tt.�, y , _ Job Address g4-D �.•Ghe.wkee: City Loi Lot Size PM /i /: C.GLTO Address &'r " ✓�. t.�eiC1 Zana z'& Phone / ,r Owner's.Name A . ± Contractor f��/" rru/f1 E>< An�yiAddress��' �' !?a5ev'1kCA License No.43783 Phone l6�77�-O.ZZi- TYPE OF WELL/PUMP:,__... .,. _ -. NEW WELL ❑ WELI,REPLACEMENT ❑ _ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ x�'SYSTEM REPAIR ❑ OTHER K 1100, �� z, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LI NE FOUNDATION AGRICULTURE_WELL OTHER WELL PITS/SUMPS _ _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing Z r7 -O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing fib- 40 PYG Specifications CeMen-� fv/ 171 Public Cl Other n Delta Depth of Grout Seal *0- 7 Type of Grout-5-1-6 1 1 Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by All T«+„Dn76v / Repair Work Done ❑ Type of Pump H.P. State Work Done ��-rt f ✓S7 Ecn,-•,,745-- Well Destruction ❑ Well Diameter , 8 Sealing Material (top 50'1 ( PvYlerr a plorl({or,M lNeil bk Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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 O Type/Mfg Capacity No. 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 11 Depth Size Number SUMPS O Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 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 applicant plust cal)fQrJII r wired inspections. e. bmw,h� Ah�rdej Signed Title: U Date- - ^' R DEPARTMENT USE ONLY Application Accepted by Date Area 2 Pit or Grout inspection by Date y/2 Final Inspection by Date N1 Additional Comments: St rye.. ;S dn--.- ❑ Stk 466-6781 O 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO {� EN 13-24.IREV:1in5t —577 XS 97IF 5 �