FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

< .Vtt1[N1 3 APPLICATION FOR PERMIT `1 I b g I' l-0 109 t%N JOAQUIN LOCAL HEALTH DISTRIC`.W-' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) _ /W instan the work herein .This mapApple in is here by wcation is ith San Joaquin nJoaquin Counry ordinance No.50.9 for alth District fsewagor a pe of INo. 1862 fort to c valll1pump and the Rules and Regulations of the Sao Joaquin Local Health District. n t'i C>\}N t4�( � City a12x.VLT01� Lot Size N 2 AC�t+ PM Job Address 17 7`J _8S"� c �` .� �Zntil�1Z5 _ Address GI4st" I-ft, 1' tAa/ H Phone �9 94 owner's Name =_----= 'aw-p s_a� nit 50`—k�i A 4��_ O License No.C�-28�310 phone -5m�) A �� .�v+1 � Contractor Address TYPE OF WELL/R�: NEW WELL . WELL REPLACEMENT 011 RUCTION ❑ I-Aosst'tetC.oG 1/ � PSYSTEM REPAIR ❑ OTHER UMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE — DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS ._ FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL BotPROBLEM AREA CONSTRUCTION SPECIFICATIONSDia. of Well Excavation G Dia. of Well Casing 2 1�• ❑ Open tom ❑ Manteca ❑ Industrial - .,,,t T of Casing -11t rt i - Specifications '4 Bills 00 /Private *Gravel Pack ❑Tracy Ep$'�-g' Type of Grout�T�Li'`r33T ❑ Othgr ❑ Oelta Depth of Grout Seal FI Public ..'J,...J._--'- NcV E-�S wo.l}RttL IDy _ I I irrigation ( IepAPWox. Depth I I Eastern Surfs" Seal Inst albd by H.P. State Work Done_ Repair Work Dorm ❑ Type of Pump _ \ Well Destruction ❑ Well Diameter Sealing Material (top 501 -J Depth Filter Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I afva(lableo wptt'whhin system permtreated if public sewer is Installation will serve: Residence— Commercial— Other \ ' Number of living __units: Number of bedrooms - - Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT.❑ Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,:.SEEPAG_E PITS..- Number I I Depth., Y-SIw,: . SUMPS Ll Distance to nearest: Well Foundation_ Property Line _ DISPOSAL PONDS n 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 rut"and regulations of the San Joaquin Local Health District. certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature Wnif'ms the following: "I 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 per armance of the for which t �e per/nit is iu ed, I n ��nil ubject to worms n's� rasa 9 tion laws of Caliiornia." 6/ }�N r The applicant must call for all requir spections. Complete drawing on reverse side. / O'AV ct..y/ Title: `��/�•r/.r _ it Date: PI o�- ®� Signed., �" FOR PARTMENT USE ONLY Application Accepted by Date 4—P?-4l Aree SJO ,` 3- IX b-3— 0 mal Inspection by �` Data Pit or Grout Inspection by �K Date� � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3833821 ❑ Manteca 823-7109 ❑ Trac1 8356385 . Applicant - Return all copies to' Ernyif omen I Ith Permit Servnces IBO He �n'A�v�e�P.O. ox 2009 5tk CA 9520 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATED PERMIT-NO. —��D 7 (f7—z,,2/9Y- . EN 3.24(REV.ons, INFO � b /Y•7�r—.f EH ;4 M Z