FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT �d 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 IntitreactIOU I:OrT&I NollaV Road/Grant City y T8t Size ukl,is PM Owner's Name C'k C-4 r CWX Address Phone Contractor 2411 P919" AYa+i $aat p=� 4 ��t@�{2 Dr'1111II>iC Ccrnddress License No._263013_Phone 415-329-2910 TYPE OF WELL/PUMP: NEW WELL $ WELL REPLACEMENT ❑ DESTRUCTION ❑ M0N%70ANI(- AV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK ISA SEWER LINES ©t DISPOSAL FLD. PROP. LINE so, FOUNDATION AGRICULTURE WELL A0 OTHER WELL _ PITS/SUMPS5W_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4" Dia. of Well Casing ler. and Ori ❑ Domestic/Private J] Gravel Pack EXTracy Type of Casing PVC Specifications OE tol ne ❑ Other ❑ Delta Depth of Grout Seal 51 Type of Grout 22 boatoulAte ❑ Irrigation 20L-Approx. Depth ❑ Eastern Surface Seal Installed by Pitt hill1il Dx'illiUR Co- Repair Work Done ❑ Type of Pump _11JA_ H.P. n/a State Work Done_ Well Destruction ❑ Well Diameterl" OnA 4" Sealing Material (top 501 $~3 betttonite seal b 2% bait. grout Depth Filler Material (Below 50') #2 ear d below heotmite a*al TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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: Well 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 ❑ 1 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 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 Cali fo /Y1 D/v/70 A,v/ �jt)c L�-(1� o f f c l� ��7 y f b -&'7 G✓.`� The applican st calMor alre iredns Ictio . Complete drawing on reverse side. Project Geolalist �i � _87 3 SignedX Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ^� /Area D Pit or Grou Inspection by Date Final Inspection by Date GaKRem// CSj� �✓oe�' s Cor-�u. Additional omments: (Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 Tracy 835 6385 Applicant- RetuFEE rn all copies to: Environmental Health Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CKO INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATES PERMIT NO. EH 3-24►REV. w s)1 ✓ _ S'0 O 0.3 A* Ss/ , ,7- !EH ` - dc[if,o��► 3S,vo pcR acre. /W_ Visirs G7__- - Z {�rGc i o