FIELD DOCUMENTS_FILE 2 - 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) 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 Address1130 ('IO )A� aT; (Cl(FSTfJ00Q `'IANoK }WP.)itY 'JCKrO,"Lot Size 9'46 QGK.. PM 55- Owner's Naame�XxO CO 0 S AddresJZDO SNiTN ST. HOMS)O!✓ TX phon�71365'fio775 Contractkv)L11/}u& kir-IL P91 U4 ress 16-16 a ISW"(44. C011460nD License N� 8Z 3q 0 Phon(4 685-66) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,IW O .T. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES So Fi 'DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WEL6C F1 -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . 2 1V7, Dia. of Well Casing '-7 ❑ Domestic/Private Gravel Pack ❑Tracy Type of Casing y C' na Specifications/_��N f� ❑ Public 171 „,,/ Other Delta Depth of Grout Seal } Type of Grout I 1kriggatign --Approx. Depth I I Eastern Surface Seal Installed by 12 LL.F _ ' KOlr rr04 Ai Repair Work Done -❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 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 I I Depth Size Number SUMPS Ll 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 California." The applican t call for all required inspections. Complete d awing on reverse side. Signed d L 6A,61 iter-At A/Cy /n/Ta: 6EOLciG l S i Date: 1g (9 9 0 FOR DEPARTMENT USE ONLY Application Accepted by Date � 7 Q U Aroa_ Pit or Grout Inspection by Date C7'' FinalInspectionby Date �.t Additional Comments: lz �!ALL c"""-4-jxC � i5� 0,�G`" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7109 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20(19, Stk., CA 95201 { G C FEE INFO DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. INFO C S EH I3N (REV.vxv A/cl EH 13]e