FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

T ' - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDVX ® s (Complete in Triplicate) s Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of t in Local Health District. S 3 i Job Address E c.< T + = U City r� -J Lot Size _'T_�ac/ PM iar Owner's Name Q-G }.n 141,C1 C-._ Address �Zto 112111 a�1 Phone ND - 350 � 00 C i Contractor AZ2cierlCc. & - eel Address PO. 5*A,51st 50-A a eel-_��License No.A1810.0 Phone#f�&-.0-9391 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK IOD t SEWER LINES DISPOSAL FLO. PROP: LINE iW-+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing XDomestic/Private Gravel Pack ❑ Tracy Type of Casing 45"hed-,40 pVC. Specifications � 1 1'1 Public C} Other Cl Delta Depth of Grout Seal 5 dee{ Type of Grout ht-64 cemell r\ I I Irrigation Z(2!Approx. Depth l I Eastern Surface Seat Installed byL. Repair Work Done C] Type of Pump H.P. State Work Done , Well Destruction O Well Diameter � Sealing Material (top 50'1 f r � Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i 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 L`1 Distance to neaftat: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lihes V Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 Dilittict. 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 parson in such manner as to become subject to workman's compensation laws of California."Contractor$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 applicantust it f r all required inspections. Complete drawing on reverse side. 1 Signed �- Title: �3.rt�� ¢�1.W� �ewp C T / FOR DEPARTMENT USE ONLY �Application Accepted by ak a . I r Data L -✓ Area 'T Pit or Grout Inspection by � Date L�.� eFinal Inspection by Date \.S7 Additional Comments: ❑ Stk 468.5781 ❑ Lodi 369-3621 O Manteca 823-7104 O Tracy 8358385 Applicant- Return ail copies to: Environmental Hesith Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK S CASH RECEIVED BY GATE, PEf1MIT N0. .))l))�� }� _f �. /tom/_ . EH 14-M 1REV.t i a 61 &7 r C1V / '• ! [,7 EH 1�2a