WORK PLANS - 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 0 py (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora cation is made in compliance with San Joaquin County Ordinance No.549 for sewageorNo. 1862 for rmit to cwell tlpump and the Rules and Regulatio/or install the work herein ns of he San. Thris t Joaquin Local Health District. i Job Address = OWG: A.s �dTSl,a t-►�� City -ffmle. >To 0 Lot Size PM Owner's NameC 9 t Address o,%aL• U Sa,3 Phone O rN N a Contractor Address 4080?i - - Lo� _ License No.�3�3�3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER X Ofto-CtO A 3r-, %k3eL DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP. LINE yd FOUNDATION 19 r± AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 3► ❑ Domestic/Private M Gravel Pack ❑ Tracy Type of Casing---?-SfC- Specifications ❑ Public ❑ Other 1: Delta Depth of Grout Sea$ 5 P T Type of Grout C. e-*i e-h L? Irrigation t-i�JApprox. Depth Cl Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ftZcr tITUrZI,Jr� UV,-i- Depth _*, Filler Material (Below 501 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 1 SEEPAGE PITS IJ Depth _---Size - _ __. Number _ • SUMPS 1-1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicantjnust cajl for all required inspections. Complete drawing on reverse side. - Signed Title: Date: .,4^` /`SR DEPARTMENT USE ONLY p Application Accepted by Date ~ tf� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:/'f s LL) 5 'l7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. E01 13-24 IREV.t a sl 3 Sa 0 :a ✓ ,.�_� �L.1-7 ` G/ 1 / TS,�._t 5 7