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. 548 for sewage or No. 1862 for well/pump and the Ruies and Regulations of the San Joa urn Local Health District, i/ � �f 7 _ � AFO�i4-o�oW 2 I Job Address Z�S� aAn Gj v `'(ue sj6se <� , Jj Crty Lot Size 1,2Ac Owner's Name 1Voi2A4AC T(ilL- __ Address FO.. Ox 2]4 U r_�C7v 94 Z� Phone. Z%�¢ Contractor (u Address &A St.24,106 4S 7 �-„�..71 License No. Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA,,TI/ON� ❑ SYSTEM REPAIR C OTHER ��tgOru,�Zf�tT' DISTANCE TO NEAREST: SEPTIC TANK N/f,� SEWER LINES .JD” DISPOSAL FLD,AK12 POOP. LINE ZZ2. FOUNDATION ` = AGRICULTURE 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 Z__ JKDomestiC/Private 1Z Graver Pack ❑ Tracy Type of Casing JNJ_�� E Specifications Sj,40 r I I'l Public pOn Other Cl Delta Depth of Grout Seal Sz+i2FAC.f Type of Grout Crm,14 r _ I I Irrigation v,'�_.Approx. Depth l I Eastern Surface Seal Installed by_ ojjh-ac4,-✓ _ Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 _-.-G seryl Depth Filler Material (Below 501 vNr -- i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RE.PAIRIADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is y available within 200 feet.) installation will serve: Residence — Commercial _ Other I Number of living units: __ Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity,._. No. Compartments PKG. TREATMENT 1 LT. 0 I I Method of Disposal Distance to nearest: t Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS LL L-1J-Distance to nearest:_,..j._Well f=oundation .. . _ . _...,Property Line_ - DISPOSAL PONDS 0 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 I rules and regulations of the San Joaquin Local Health Di§trict. 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 t a for all r quired nspections. Complete drawing on reverse side. Signed X Title:� /7si/04� Date: FOR DEPARTMENT USE ONLY �' s Application ccepted by __.-_....__ Date Area E. Pit or Grout Inspection by Date Final Inspection by j Date Additional Comments: �� t J � ��I [/ ' /�� _ ❑ Sik 466-6781 O Lodi 3 21 ❑ Manteca 823-7104 ❑ r cy 835-6385 Applicant . Return all copies to: E ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMI7'NO. ,.Eli 13.241REV,1/n51 4j' J � �? 14k— EH 11-26 ( L• r I 1 r