FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

`WI APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIC 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application 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 the San Joaquin Local Health District( Job Address I v Oq � Mom. n City cq( Lot Size PM � MG� Address - A�n� S��.n Phone(2o '/,63- Z5�63 Owner's Name 1 �"� Contractor 14914,04 /-//(/� Address 710/-430 T'19 AYe� �d�ls�! Li ense No.9.5-2504076Phonr 5gQ-+�SZ/ TYPE OF WELL/PUMP: NEW WELEY WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE/PAIR ❑ OTHEP �R M9"v6r,a9 LN) DISTANCE TO NEAREST: SEPTIC TANK >IDO SEWER LINES >WOO DISPOSAL FLD.> PROP. LINE >� FOUNDATION �� AGRICULTURE WELL d r OTHER WELL >�0O PITS/SUMPS 7L&V 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION �X ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation /O Dia. of Well Casing ❑ Domestic/Private �<Gravel Pack ❑ Tracy Type of Casing --Y--A• ko PVC Specifications F"1 Public r1 Other n Delta Depth of Grout Seal Wlk Wh 7f 4V►110cdrType of Grout �t�1� I I Itrjgatjgn go!Approx. Dept I I Eastern Surface Seal Installed by _ MOMt pTA epair Work TAA ❑ Type of Pump t H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') gro�T 7y Sur ACS \ Depth 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 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 J FILTER BED ❑ Distance to nearest: Well Foundation Property Line l SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 w' S aq unt ces, state laws, and 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 h this pe it is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California. ontr or's wing or su -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 must call for all quired inspections. Complete drawing on reverse side. Signed X Title: QLD �e4/, Date: fiml LL al �vst 601'ARTIVIENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Date Final Inspection by _ Date Z \ ' V Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 89.11-71104 ❑ T acy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 01 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. n^ / + EH 13-24(REV.I/M 5! INFO T}'1+t'P l 01,01D / CASH Z'lJ �I ��