SITE INFORMATION AND CORRESPONDENCE_FILE 1

Home Browse Search

%W APPLICATION FOR PERMIT 1 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 Addressll3J No+Jeco r-T Lcars J0Oa twole f PIY5 '7Ck1O1'/ 3.46 ac L.C. PM Owner's ,Naamer—)(.'?O At CO q SA AddreJZD0 911 51. HO L STOA/ TX Phon(713)65677 5 Contract lF-V1 L-HAU& It/FLL DK«A6ress 167& ai-90119). CONf012� License . s2 3q'O Phor 4ls 685-(,61 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,e DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SO FT' DISPOSAL FLO." PROP. LINE 10 FT_ FOUNDATION AGRICULTURE WELL OTHER WELI510E FI rPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �/,,1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2 r h, Dia. of Well Casing • ( N ❑ Domestic/Private A<Gravel Pack ❑ Trac Type of Casin 7 Y r' g1o+ S $ch'.ef ,�/ Y Yp g Specifications I1 Public 71 Other Xbelta Depth of Grout Seal 20 } Type of GroutCENENGQSrZN - ' I IIIrfnyav rn o2 N� —Approx. Depth 1 I Eastern Surface Seal Installed by 121 1.L-� _ epau Wor 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 I 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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,1 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 II Vn Oil C 1 A�E�///11/� /N� itle: U.I EO�.OG l S 1 Dater ! 9 q FOR/.DEPARTMENT USE ONLY Application Accepted by Date � 7 Q U n Area/lyi _� Pit or Grout Inspection by Date //7 y Final Inspection/n by i X L Additional Comments: &. Qe 2 ' . '111e Ccul,&cK � � //L-ei_ ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manta 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C. Z t FEE AMOUNT DUE AMOUNT flEMITTED RECEIVED BY DATE PERMIT'NO. INFO Ell;3-24(REV.11.5) 5�31go 0 042 EN 1418