FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Address S South Of City TXaCy Lot Size PM Owner's Name l?L t C i i .�, __ P. D" Box Address Mad sto X95353 Phone209 57_ 9-33-A Contractor P (` FYnlnr^ 1780 Vernon St. (916) }' — Address ltaseyi 11 P CA QS471 TYPE OF WELL/PUMP: License No. 265556 Phone 783-9733 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I-1 Monitor we 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER 14-35,A--02SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantecarr-- Dia. of Well Excavation $ ❑ Domestic/Private El Gravel Pack Dia. of Well Casing �+ 11 ❑ Tracy Type of Casin (`1 Public f 1 Other g POty --- Specifications Cement— fl Delta Depth of Grout Seal _ 17.5 f t I I Irrigation __— Approx. Depth I I Eastern — Type of Grout BeII_t0_Illte Ll Seal Installed by Repair Work Done - - Type of Pump H P — ❑ State Work Done Well Destruction _ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I I septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) _ 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. ❑ Capacity__—_ No. Compartments Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE El No. & Length of lines FILTER BED ❑ Distance to nearest: Well Total length/size Foundation Property Line Cl SEEPAGE PITS I I Depth SUMPS Sae _ Number F Distance to nearest: Well DISPOSAL PONDS El Foundation 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 Di3trict. 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." p y persons subject to workman's compensa- tion applicant must callforall required inspections. Complete drawing on reverse side. Signed X _aI D �L Title: Pr+li n �� Date: G'-2--3l�q-3 ` FOR DEPARTMENT USE ONLY Application Accepted by �_ Date �= Area i Pit or Grout Inspection I Date Final Inspection by Additional Comments: Date El Stk 466-6781 O Lodi 369-3621 M teca 823 7104 5-6385 Applicant - Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton 3Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO NT REMITTED RECEIVED BY H GATEPERMIT NO EH 1321(REV I/x sl