FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. ,,�`I� . Job Address 'I1A�\\��.` J- J%Q/�.1.' LA2c "--(lG>�/ City ==- Lot Size PM Owner's Name La& / �""-"�z A'd/dress dw'�'/✓'f' �'_'^J'�''�� Phonez /v 4166-2Z6 Contractor• /�,t.t{� Address w'1 OK'I License No��7 y 'iUYPhone �6 y (12- TYPE OF WELL/ UMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER a- ✓ 2?r�-��/ DISTANCE TO NEAREST: SEPTIC TANK l� SEWER LINES /V DISPOSAL FLD.�y PROP. LINE FOUNDATION 15- AGRICULTURE WELL OTHER WELLPITS/SUMPS-4 V,23$A/4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing x 'Y Domestic/Private AGravel Pack ❑ Tracy Type of Casing Pk-- Specifications (-I Public 5❑cnOther �-0elta Depth of Grout Seal ' 60, E t. Type of Grout I I Irrigation l—Approx. Depth I I Eastern Surface Seal Installed by (^t"ri'�^ Fy�e Repair Work Done ❑ Type of Pump H.P. State Work Done _ ( Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 L/ 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 _ C Character of soil to a depth of 3 feet: Water table depth S SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line TC LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 Di1trict. 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, 1 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 parsons subject to workman's compensa- tion laws of California." The applicant II for_l omplete drawing on reverse side, /`V"?`� - 612-5 �6 Signed %V Title: (//`)N�O�iO-UiE ONLY Date: R NT USE ONLY i Application Accepted by Date_� `� Area Pit or Grout Inspection by Date_ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INrO CASH • EH I3-24 IREV.1/x51 E11 Ir-M 1�