FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLIC'ATIOWFOR 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 Rules and Regulations of the San Joaquin Local Health Districlt._ 1 Job Address _ Lf64 6 Wes+- Padd o /PIC(ce, City LOd I Lot Size /1"�' g15C71491-q-21 0 pM OST,-lW 3(rrD Owner's Name r'I I +O Dp-ve IO er Address 1F2 1 Paddock Place W1 CAPhone6lerro. EnvtronntenkLl erv,4 ebContractor Y IOra-floh 5V . Address P•O, Box 5qT; V Pny;Hf- License No.50-2(0 40 PTYPE OF WELL/PUMP: .3 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 5O SEWER LINES MMPI�,�'rQOr DISPOSAL FLO. NA PROP. LFOUNDATIONKyAGRICULTURE WELL , OTHER WEL PITS/SINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of We ❑ Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing PYG Specifications (1 Public r�O,,ther MWnQiI}�gry�11a'Delta Depth of Grout Seal minl mgm 5 / Type of Grout (D�G maon � I I Irrigation 111Approx. Depth I I Eastern Surface Seal Installed by._Gaff Fra C&r Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 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 Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 D3trict. 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."Contractors 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 app li must call fc all/r? ned inspections. Complete drawing on reverse side. Signed Al, �, ULi.�r ¢.rte Title: Date: \�JSra/h F v,rd J� c� OR DEPARTMENT USE ONLY Application Accepted by Date �� Area �N q Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O D Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CACol FEE [,AMOUNT DUE AMOUNT REMITTED INFO CASH REC IVED BY DATE MI-"X7 EN 1}I�IREV.I/xs) �0V5 .� EH 147a