FIELD DOCUMENTS_1986 - Laserfiche WebLink

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�- 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 Ryles and Regulations of the San Joaquin Local Health District. /vct. ,,I Job Address V 61n/r✓'(�/t}Ile _ City / Q� Lot Size pM Owner's Name lNf g-4j K cr__ O/J/./-��Address 5iU (No -( ��P r- - Phone Contractor 5 Vole ddress�(2$F146 /b y^� TYPE OF WELL/PUMP: License No.�2G7�Phone GCIJ NEW WELL WELL REPLACEMEDESTRUCTION ❑ PUMP INSTALLATION�„ SYSTEM REPAC�/1fl.ClApS%C! DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ER WELL IqT D USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOICATIONS PITS/SUMPS I^ ^a /ItAN(fpQ E] Open Bottom ❑ Manteca Dia. of Well ExcDia. of Well Casing ❑ estic/Private Gravel Pack ❑ Trac ❑ Public y Type of CasingSpecifications r Other ❑ Delta Depth of Grout £ F//9WrnQ� ❑ Irrigation $b-/�d pprox. Depth Cl Eastern Type of Grout/Vfs41 C,Fijf)�,i. Surface Seal Ins � Repair Work Done ❑ Type of Pump c314,944 H P �1 2 - 1 _ Well Destruction ❑ Well Diameter —�to ate Work Done Sealing Material (top 50') Depth Filler Material (Below 501)TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRON ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ available within 200 feet.) Commercial_ Other Number of living units:_ Number of bedrooms - Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth ' PKG. TREATMENT PLT. ❑ CapacityNo. Compartments Distance to nearest:., Well Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 signat a 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 o ome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th own :"I certify a ' he rformance of the work for which this tion laws f Califom' ." Permit is issued, I shall employ persons subject to workman's compensa- The applicant r ui i pectic Complete drawing on reverse side. Signed (/YI Title:-&Y-1 r/A/�i 6:r Date: 2:7 r1.tN-Akr— R EP ENT USE ONLY Application Accepted b � /� _�� Date Area_ �JZ' Pit-or Grout Ins cf by Date Final Inspection by Date Additional Commen r ❑ Stk t- Return Lod( ❑ Manteca 823-7104 ,r.. 714- 0001V Applicant- Return all copies to: En 'onmental Health Permit/Services 1601 E. Hazelton&i Ave., P.O. Box 2009, Stk., CSA 95201 L!/ FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE N/ PERMIT'NO. i 1C211flEV.1/e 5) y(� C�/I a'� ' i 14ffi 7j � O Z � •do ISI 1 as. -1SI