FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT '— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 South Of $0uth !`nrral Anl 7 n R d City Trac � Lot Size PM P. 0. Box — Owner's Name R JC T ('a 1 l., yi repro Address Mnd y eGto_,__CA 95 Phone 209) 579-3371 1780 Vernon St. — Contractor P_ r FYnlnr^�; (916) ------�� —�_Address BQsevi 11 e, GA 956,78 License No.265556 Phone 783-9733 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [� Monitor we 1 PUMP INSTALLATION ❑ SYSTEM REPAIR P DISTANCE TO NEAREST: SEPTIC TANK OTHER Zlj_35A-02 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 81� 11 Dia. of Well Casing 4+ IF Domestic/Private ❑ Gravel Pack ❑ Tracy T ["] Public _ ype of Casing PVC __ Specifications Cement- F1 Other ❑ Delta Depth of Grout Seal _ 17.5 f t I I Irrigation ___ Approx. Depth I I Eastern - Type of Grout BeII_t0_nit_e_ Repair Work Done 11 Type of Pump H P Surface Seal Installed by Well Destruction El Well Diameter State Work Done _ Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is (A Installation will serve: Residence— Commercial_ Ot available within 200 feet.) her _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/MfWater table depth Type/Mfg PKG. TREATMENT PLT. I-]] Capacity No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well DISPOSAL PONDS LlFoundation 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Y�i�,�- � /� L Title: U r"+lt n -G —23 - P 9 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date � -J JCJ''� Area I Pit or Grout Inspection Date Final Inspection by Date Additional Comments: C ❑ Stk 466-6781 ❑ Lodi 369-3621 M teca 823-7104 y Applicant- Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton 835-6385 3 Ave., Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO R RECEIVED BY DATE PERMIT NO. H 13.2 (REV,iiHsi �f5 H 14-28 TZ ��`/