FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT — PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT P ENT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA REC D Telephone (2091 466-6781 NOV 17 1958 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 19 SAN JOAQUIN COUNTY (Complete in Triplicate) Nv ,,..... JJE#g PUBLIC HEALTH GERvICES 1 19;Q�pfy plical on is A�IIIYM®R1AfiN7M1l TJ 1�tl$dOMaquin Local Health District for a permit to construct and/or install e w 11 ud the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru Local Health District. ,� yy 3i�Vr,Yu` City Lot Size PM Job Address Address QT' Zm •�1�� 1 i �L.t7C�frS_— �� 1�y7t'fY 1✓J9 V /J7.GJ 1 Phn Owner's Name 7„ G / n Contractor ail Address Nacl ��License No. ,r q Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 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 J Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ of Casin SpecificationsTracy Type 9 ❑ Othyr n Delta Depth of Grout Seal Type of GroutL"I (1 Public ' G.- I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Walk Done _ Sealing Material tto SO'l o--f" top,t ,0� Well Destruction ❑ Well Diameter 9 P / � Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will some: 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI 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 Di§trict. 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 subcontracting signature canities 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 applica t m t ca r all to Ired ins c' s. mplete drawing on reverse side. // � Signed X14V+ lh.r Title: 5�.�..• �^" Date: F EPARTMENT USE ONLY Application Accepted by .._ Date Area Pit or Grout Inspection by Date Final//Inspection by �/ LLL� Date Additional Comments: 2-_3!0i �'�� v N� tt//M- ' ��i1""-` �'t'� 7�5 ❑ Stk 466-6781 ❑ Lodi 36921 ❑ Ment ca 823-7100 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EH 13 N ll EV.rix 5) EN 11-7a