FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 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. Job Address 900 Sro f�iy �ee/(�� C4y/E - - - -- -- City ZOO/ Lot Size PM Owner's Name _.1[AA VO 0/L C pyj��t� Address .`2'21Tj/�lL0CM �` _1 one 4 ^J� 7O Contractor A� Jr,.7W —Address AX IV ZZ /Tc AIQ, [i4 e License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ 'DESTRUCTION 71 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER jiti 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 -- i Industrial i_1 Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing *Domestic/Private tN-Gravel Pack ❑ Tracy Type of Casing_91A VO Pyc Specifications w Public -' Oter FJ Delta De th of Grout Seal 2 P _ �z Type of Grout 66Viy/7Z .meq rri n �/ �Q pprox. Depth i.:1 Eastern Surface Seal Installed by Repair or • ne Type of Pump H.P. State Wo Done _ Well Destruction C Well Diameter Sealing Material (top 50') C Depth Filler Material (Below 50') IC. TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION 7 DESTRUCTION (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ," Method of Disposal Distance to nearest: WeR 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 -- 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 woA for which this permit is issued,1 shall riot 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 Ca rniia. The of lican ust' Ir for all req u' in ons.lComplete drawing o reverse side. // r Signed Title: "IAI- 4 � Date: F D RT USE ONLY ` B�tXA��Y Application Accepted Date 0; a Pit or Grout Ins by �( alte �f-a )Final Inspection bye Date �_S Additional Comment Stk 466-67$1 ❑ Lodi 369-3621 ❑ Mantep 7104 ❑ Tracy 83�r6385 � �y � Applicant - Return all copy o: nvironmental Health t/Servi��` 1601 E. Haz�elton�Av�. P.O. Box 2009, S/�f(., A 95201 O A ' FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. + EH1320 IREV. e. -* �3 /TyeLJ EH 1026 �'// V