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 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / (Complete in Triplicate) 9i6 366 r�70 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' made in compliance with San Joaquin Co)nny Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1-pd; viler 1At0AW Dao r C U�( / C7Wf �� IT1 1 city —"` / Lot Size PM \\._. Joh Address �T'A—�,��(t � �p�[ Owner's NamelLlTr�LL1.L__"/�✓� IS aAdtlreo•_�7y � ABT' F•«w,��/ 1//N/�('I y7 Pones Contractor___SL11_� Address Q�VS ,Wff /1481 License No. I1�� 2Trl Phone_ TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 _------ _._._____.. 71 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private 0 Gravel Pack t.7 Tracy Type of Casing Specifications p / II Public f7 Other I I Delta Depth of Grout Seal Type of Grout L{N�N Ug/N P I I litigation ___ Approx. Depth I I Eastern Surface Seal Installed by --- Repair Work Done I I Type of Pump H.P. State Wor�k""Don//BB��_ II Well Destruction 1 1 Well Diameter Sealing Material (lop 50'I CM?A1 p(.UT7/Lh of .' (6, t Depth � YP f i— Filler Material (Below 50'1 --- N TYPE OF TI NEW WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 (_1 Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. LI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE I I No. & Length of lines _ _ Total length/size FILTER BED— - _--- I I— Distance to nearest: Well =__ - Foundation _ Property Line t SEEPAGE PITS I I Depth _—.--.—.Size .._--—.--- Number SUMPS I I Distance to nearest: Well Foundation _— Property Line DISPOSAL PONDS I I 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 rogulations 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, 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 persons subject to workman's compensa- tion laws of California." The applicant ust call for all red 1 s omplete drawing on reverse side. e �y yf{' � �}I Signed X l' ._ Title: 6"'r7 I e / OGI 9 1 Date: Z 9 FOR DEPARTMENT USE ONLY czeo, AQ fit,, ^ kd tX15�Cv Application Accepted by _ - Data T— �'u !_ Arealox 0 11'. � Pit or Grout Inspection by Date-77 7 Final Inspection byJ./ -- Date Additional Comments: 0 Stk 466-6781 0 Lodi 369-3621_i 0 Manteca 823-7104 0 Tracy 835-6385 Ol Applican�Retpr�all co ies to: Envir nyel eV Permit/Servi as 1601 E. H n Ave., P.O. BoK 2009, Sik., A r, FEE gMOUNT DUE AMOUNT REMITTED CK� RECEIVED BV DATE PERMIT'NO. . EH 1324 IREV.lrxsi EH 14 26