FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

4 APPLICATION FOR PERMIT 04 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. l�'$3�0 Job Address'? /� � C�/9�C�C�' /f✓e �/,�s ,,,Ciitty_s `lt Lot Size PM Owner's Name h/" w�''/� Address /�fK� /U®�!`f Y✓ .STk1kT__4 Phone 49,00— Contractor QqContractor Address O J50 License No;��2 6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEF W,7, v7X/g� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation,Un,�/ Dia. of Well Casing O ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .SCh-"!�/O PU Specifications f ❑ Public ❑ OIiher ❑ Delta Depth of Grout Seal 6dW_t>By Type of Grout ❑ Irrigation L-Approx. Depth 1:1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump /fj/? H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DEST CTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: idence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth o 3 feet: Water table depth SEPTIC TANK ❑ Ty fg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance t Barest: W Foundation Property Line LEACHING LINE ❑ No. & Lengthof I Total length/size FILTER BED C1 Distance to near Wall Foundation Property Line SEEPAGE PITS ❑ Depth Si Number SUMPS ❑ Dista to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have p epared 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."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 applican strcall f(oy/1 uiirred i ctions. Complete drawing overse side. r c ,[ Signed X I C�X/Kt_i!/ ul/• 'l� Title: VA)LOCI— Vc/ /07/J/ Date: R E' A M BE ONLY Application Accepted by Date -3 �, Area Pit or Grout Inspect! b Date Final Inspection by �,( Date Additional Comments: na� .nue / n� !��-��q•-,/ �h2 ,�G''P/' �72 - A Stk t- Return ❑❑ �ronm Manteca 823-7104 ❑ Tracy/835-&i85, P. , �tf� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 _ FEE INFO OUNT D AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. EH 1&24+ EH 14-281REV.1/es) 3j. 'J-7q _.O.lr, tr -''G - __ ._'_„A /{i,4