FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR 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 Sari 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. c Job Address �� _� -_ Cit � �l.ot Size ti�SO PM �_�l_��_ _ Y Owner's Name C�,N Address �� Ste _ `� . Phone ( b11-5L�00 Contractor _NtCC-�2�,0. .';C Address ``TV - EQ�'F O�� l � License No.'*Wbd� Phone —SSIS TYPE OF WELL/PUMP: NE ELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [_l SYSTEM PLPAIR Ll �~S`\f--IQT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S� _ DISrERWELL!�71 1FLD. uJ PROP. LINE FOUNDATION AGRICULTURE WELL OTITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin �- ❑ Domestic/Private I Gravel Pack ❑ Tracy Type of Casing_ PyZ-1__,, ++ Specifications ['I Public I I Other (-I Delta Depth of Grout Seal __� 1 Type of Grout 1 1 litigation -_ Approx. Depth I 1 Eastern Surface Seal Installed by nC�-«0.-CIL P v' " Repair Work Done Type of Pump H.P. _ State Work Done Well Destruction Well Diameter �- Sealing Material (top 50') M10��OT�� UL Depth ~ 3D 47*-- Filler Material (Below 50') TYPE OF SEPT WORK: EW INSTALLATION I I REPAIR/ADDITION ! DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resided _ Commercial Other Number of living units: _. ___ Nu er of bedrooms Character of soil to a depth of 3 feet: ____ Water table depth SEPTIC TANK I I Type/Mfg _. _ _ CapacityNo. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: ell ___ Foundation Property Line LEACHING LINE I 1 No. & Length of lines Total length/size FILTER BED I ! Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS I I Depth _ _Size _ Number SUMPS I I Distance to nearest: Well .. _ Foundation Property Line DISPOSAL PONDS i I 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 tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPAR;EMEYZ ONLY `) Application Accepted by I Date _b— O a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA595201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1L EH 13-24(REV. EH 14� S . ©o �-- C - ��oil �s�—tH3ti