FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA R E C E I V ED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jUL 9 1987 (Complete in Triplicate) `'��/� 1�� T. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta{,[RB'IyOrK s I 'This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rpt 6(tl ( �f the San Joaquin Local Health District. s� / Q 1 _ 1 Job Address Li 4 �+ 4 NLf-, t F, 1 e' z Sh, c P f /VP.City �Toc LILT ,Lct Size 02 x14 L PM $4W Address 1 SFS ^�G�Lj OFA - 47 SCI�1G✓ Phont` i /- 150 Owner's Name 1676 / p /� (�� %JELL I oa A-0 r to NCO KD-c?License No.Jo Z'3 yU Phone 1T 6�'.7 661 ContractoFyIL '>Q k/r.Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N\Ct A,of4 iS Ely, DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES '41SPOSAL FLO. PROP. LINE _ FOUNDATION __ AGRICULTURE WELL 10z, .OTHER WELLz r'�' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT12NS If C7 Industrial M❑ Oben Bottom ❑ Manteca Dia. of Well Excavation_ 10Dia. of Well Casing n Domestic/Private 1°f Gravel Pack ❑ Tracy Type of Casing. Specifications I') Public f_.1eal Other FI Delta Depth of Grout SType of Grout Ce E«.r.. I 1 Irrigation 1402ADprox. Depth I I Eastern Staiace Seal Installed by�y f �I�U NULL Repair Work Done LJ Type of Pump H.P. _. State Work Done _ Well Destruction (7 Well Diameter — Sealing Material (top 501 -- -- Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 206 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 Caac' No. Compartments PKG. TREATMENT PLL Cl Method of Disposal Distance to nearest: Well � � ! Foundation_ _ Property Line LEACHING LINE I.1 No. & Len mes .. Total length/size FILTER BED I I Dis a to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _.__- Size _,_ Number SUMP If Distance to nearest: Well _ Foundation — Propeny Line DI OSAL PONDS LI I hereby cattily 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, 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 canities 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 m an for al rtd wired inspectio ./Complete drawing on verse side. J Ti G Signed X . Title: ry /1'� °� Date: �''"� // Q �R P M SE ONLY _ /fit Y`'z` V 7; Application Accep a y Date / T — Area Pit or G ou fns .o Date Final Inspection by 6�Q.6s Date1 _ Additional Comments: 0 Stk 466-6781 O L 369- Manteca 823-7104 ❑ Tracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ffJAtM1M10UNT DVE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NOEH I3]I(REV.Irn 5I ,E/// 13$p