FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

/Q �N RAY 'A� YS APPLICATION FOR.PERMIT A two) SAN JOAQUIN LOCA!.: HEALTH DISTRICT 1601 E HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ui (Complete in Triplicates h' Application is heteby made to the San Joaquin Lbcal'HeaIth District for a permit to construct and/ install the work herein described. This application is made in compliance with}pn Joaquin County Ordinance No 549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. / ,FARCES-5. " J 4 s4 _ Job Address r/¢$Tr'i4'♦VT1JA/E �Dr4�" �- "City "Lot Size �SdX/� 'PM Owner's Name IIJ2 : 014 CMM—P, __. Address .3 00 ' -5-a p�700 Phone y 4f t /�.[�. ,F3o.Y S Contractor Gil ��-/�� Address /o Vl1 License ho.C�� 6SB786Phon 9�6 TYPE OF WELL/PUMP: NEW WELL-0 WELL REPLACEMENT 1--i ;i: DESTRUCTION -0 PUMP INSTALLATION ❑ SYSTEM REPAIR O t: OTHER gr DISTANCE TO NEAREST: SEPTIC TANK _l+ L SEWER LINES - DISPOSAL FLO. //*•% PROP. LINE /� r FOUNDATION r AGRICULTURE WELL 11.S_ '04 OTHER WELL 0"V4 PITS/S NAPS S �m•It I INTENDED USE TYPE OF WELL" PROBLEM AREA "" CONSTRUCTION SPECIFICATIONS 00 /NGS u 15 industrial ❑ Open bottom , C1 Manteca ` Dia. of Well Excavation 20 -_ Dia. of Well Casing "— 1_3 Domestic/Private l-1 Gravel Pack '; ' racy Type of Casing Specifications l Public I-1 Other W0_ fl Delta Depth of Grout Seal Type of Grout$faL[b� r. 1 Irngdnon 2Q Approx. Depth ,1 I Eastern Surface Seal Installed by.4 V 4- 4J PRIA' .Z6 4C rr Repair Work Done u Type of Pump H.P. State Work Done , ~A Well Destruction ❑ Well Diameter Sealing Material liop 501 Depth Filler Material (Below 50'1" TYPE OF SEPTIC WORK: f NEW INSTALLATION 1"1 RE_ PAIR/ADDITION l I DESTRUCTION I I iNo septic system permitted if public sewer is n1 available within 200 feet.) 1`� Installation will serve: Residence— Commercials ,Other Number of living units: Number of bedrooms Character of soil to a depth of 3 toot: ° Water table'depth SEPTIC TANK ❑ Type/Mfg a Capacity NoMe o. artments WAPKG. TREATMENT PLT. ❑ r c iY:. Distance to nearest: Well Foundation Property �t i LEACHING LINE Cl No. & Length of limes �^ Total 1 FILTER BED m 0 Distance to nearest Well Foundation ftj tt r ME LrNl SEEPAGE PITS 11 Depth Size Number �C SUMPS L1 Distance to nearest: . Well Foundation Property Line ISDN DISPOSAL PONDS D ._ 1 hereby cavity that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dibtrict, a Home owner or licensed agent's signature cartifies the following: "I certify that'in the performance of the work for which this permit is issued, I shall riot 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„t shall employ persons subject to workman's compensa- tion laws of California." �} e k - I The applicant must call all required inspections. C late drawing on reverse side. T Signed X Tide O ♦ 'T Date:- J, ate:- t'71F'f x.c JvC FOR DEPARTMENT USE ONLY j Application Accepted by Dace Ato- A, ea ✓✓•o ` Pit or Grout Inspection by Date Final Inspection by Data r Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369.3621 so ❑ Manteca 823-7104 0 Tracy 835-6b85 ; Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P.O. Box 2009, Sik., CA 95201 U t ; FEE AMOUNT DUE ; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 1 d f • EH 13-24(REV.i i n st gZ� / E fv' �'j•J• 1 V EH 142E I y ✓