91-3211 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ri (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 Address 7`7lGkU� ,/ City - t9� 1 Gv`Lot Size PM r � �1 Owner's Name dS//� �� ,4-V �� G`I G Address + kON Phone - r ► r Contractor 1S �r I'f2L Address I IahL�r� e M�l1r�S ] License No_f2-5,5_-5__ Phone w5�Z — TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT XDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 20 ' SEWER LINES �� DISPOSAL FLD. PROP. LINE ■ -&� �a��,l��FOUNDATION=�_AGRICUL.T.URE-WELL, ,OTHERWELL e4, —_P_ITSJ.SUM.PS_- - - .. . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ „-_ Dia, of Well Casing C_-9-Domestic/Private RGravel Pack ❑ Tracy Type e of Casing4 y� Specifications DD__ i'1 Public Ll Other 17 Delta Depth of Grout Seal Type of Grout]. r, I Irrigation Approx. Depth I I Eastern Surface Seal Installed byEif�� Repair Work Done ❑' Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 + + Depth Filler Material (Below 501 TYPE OF SEPTIa WORK; NEW INSTALLATION (') REPAIR/ADDITION I I DESTRUCTION f 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 l Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size Rp .£' FILTER BED ❑ Distance to nearest: Well Foundation Property LineA'�� r ' SEEPAGE PITS I i Depth Size _ Number n"1111,1111' ' UjN �I�i�IT • SUMPS Ll Distance to nearest: Well Foundation—,Pr _ 9 rrF1 . ti. ) ,LS '--' V5�-.-e _��t.� Af�r -.A �.. - + Y' w'�"iV s2�4-.i.r�IJ. ..tom— 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 DrItrict. 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." i The applicant must call for all require inspections. Complete.dr'awing on reverse side. l Signed X Ls Title: - Date: x-12^ 911-1 k R DEPARTMENT USE-ONLY Application Accepted by t Date ` _/ Area Pit or Grout Inspection by�Ll Date Final Inspection by Additional Comments: ? 4► ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ M nte'ca 623-7104 ❑ Trac 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 t } x/01 cuc,// y3�y7 /y�/y3 � k FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH// DATE PERMIT'NO. +.EH 14-24 tREV.i/K51 /� EH 14-Z6 L T