ARCHIVED REPORTS_XR0012740 - Laserfiche WebLink

Home Browse Search

s. z, Now 11 M ME IMM-11 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (299) 466-6781 PERMIT EXPIRES I YEAR F^;"fA 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, 1E62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address :5J�kP rJ!� ✓t ►.• City�[?dG Lot Size_ PIER 2_Z::5L1 C.lipfff C#-, Owner's Name &((.t Pol ftmlra rv% nrrrl to ch ddress 1r�xLrl clr l, t q q:S-3-3 -- Phone Z- 1 t� 15.75 43,c,'tA AW!, Contractor,pC, C?:o Wa'h0L\j-^_Address Rr!,ejr;F ZS/•i,r License No.�/n.�"iS(n Phone !liW3-973 3 TYPE OF WELLIPUMP: 3 NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER VVELL_-'_'� PITS/SUMPS INT LADED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑Manteca Dia.of Well Excavation ' Dia.of Well Casing i? ❑ Domestic/Private Gravel Pack ❑Tracy. Type of Casing PSL'- Specifications ❑ Public ❑��O,th"er ❑ Delta Depth of grout Seal&1 ' i'D suirme-C Type of Grout 0 Irrigation prLApprox. Depth ❑ Eastern Surface Seal Installed by._,___ Repair Work Done ❑ Type of Pump H.P. State Work Dore Well Destruction ❑ Well Diameter arl r, Sealing Material Itop 50'1 MoAttbrr1,5µ]et) Depth (0Q _ Filler Material IBelow 541 T F SEATIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public sewer' 9, �� available within 200 feet.) Installation will see Residence___. Cammarcial— Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: r table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT,❑ Method of Disposal Distance to nearest: Well_ ation Property Line h ai LEACHING LINE ❑ No. &Length of lines length/size FILTEI BED ❑ Distance tot st: Well'_ Foundation Ara Line SEEPAGE:PITS Depth.— Size Number ` . SUMPS E3 Distance to nearest: Well Foundation Property Lina r � P17SAL PONDS ❑ h 1 hereby certify that Lhave prepared this application and that die work will be done in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health Distri.;t. Home owner or licensed agents signature certifies the foll0wing:"f certify that in the performanceof the track for which this p•:rmit is rued, I sfw11 not ; -re employ any-person in such manner as to become sub set to workman's compensation laws of California."Contractor's hiring o.sub-contracting signature - t cert fias the fallowing:"I cer ify that in the performance of tho work for which this permit is issued,I shall employ p6rsons subject to workman's cumpensa- tion laws of California." t The applicant most cal!for all aired inspec' s.Complete drawing on reverse side. t�G[KQ 1�rtG�U � I. Signed"` e _ Title: ( ry X1%1111 Date-, FOR DEPARTMENT USE ONLY Application Accepted by °' " �� - --- pate - x -aArea .-r'".':,:C ,p' '",�•`" sit. - _ - Pit or Grout Inspection by.' Date Final Inspection by __ Date Additional Comments: ❑ Stk 4W-6731 ❑Lodi 369-3621 .... ❑Manteca 823-7104 ❑Tracy 835-6385 Applicant-Return all copies to:.Environmental Health Pe rnit/Services 1601 E.Hazelton Ave..P.O.Box 2009,Stk.,CA 955201 FEE INFO AMOUNT DUE AMOUNT REMIT TED CASH-- v REV.treRECEIVED RY DATE PERMIT NO. +EN 11241 51 pr•� j .�.1 '44; r �Ft q� C'....j r C"'_ ^Y7 / .r