FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT •N JOAQUIN LOCAL HEALTH DISTRV PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVpr7 Telephone (209) 466-6781 e PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SA,,44 .f 1993 PUBLIC H QUIN COUNTY (Complete in Triplicate) EM/IPwpl+rr,jE�A�LTH gERVIC ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe$.'TM3lappl�6'6�i6°r1Q(tf made in compliance with San 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. �,,1 11 Job Address l01 I &C A1City C Lot Size PM 11 II p,n.o 8or (�340o J c8m) 591- 1,466 Owner's Name he Ur11.c7 �OdS Address UehJe� . C"0 $011'7- 3t'DO Phone C¢e1) S35 • 19L6 `� 5VVAk _, CA zo9 Contractor 5 P_c..�'wv. Dt h Address Z5 E. tls�,Ake 51CA License No.51Z2Gg Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ )IW-Z,MW- PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER 17, Monr6N\rtca y._ DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINESDISPOSALFLO. PROP. LINE 10 FOUNDATION —i-Q= AGRICULTURE WELL 25 OTF�I�R WELL 5p� PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom IT Manteca Dia. of Well Excavation $ Dia. of Well Casing 2 ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing ;Z INC, Specifications//�� 0 If F"1 Public f1 Other ❑ Delta Depth of Grout Seal Type of GroutS�RP i k IRIC(ipn,n Approx. Depth f I Eastern Surface Seal Installed by _ Repair Work D%e ❑ Type of Pump H.P. State Work Done_ s Well Destruction ❑ Well Diameter Z Sealing Material (top 501 A)ec.{ C¢.1nen'r Depth 20 Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other xx�4 r1�3. ` Number of living units: _ Number of bedrooms X^J 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and C 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 t call to quired ' ctions. Complete drawing on reverse side. �/ Signed X Tide: z ej cDate: /-114- 9I! � 'r FOR DEPART ENT USE ONLYp p Application Accepted by /� / / t � Date �0 �j Area Pit or Grout Inspection by /220 GI/,- d,] ate final IQ nst'coon by Date Additional Comments: -C LtP L . 6e1 'u✓'t' Oh+ �Z rOot ❑ Sik 466-6781 ❑ Lodi 36b-3621 ❑ Ment 823-7104 ❑ Tracy 835-6385 T Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 O� INFO AMO4UNT/��tDUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMI7 NO. • EH 13-24(REV.tin SI /� 1 O ga� --m �o q3 �3-.aX-1 EH Ix 211 V t