FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

PUBLIC HEALTH SERVICES • SAN JOAQUIN COUNTY • P.O. Box 2009 (1601 East Hazelton Avenue) Stockton, California 95201 —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. (�77 }� ref LAA 9 (�O L R1/ City C AT17 i 1 a rt' Lot Size 14'S J5 PM Job Address nn Owner's Name 5bxn PF_ A 6� ,-DE Pa7Address LAN R01! G Al- Phone)if 9&;Z-y )Lc �R7j 0 �R-o JC-y/ p�p 2- 1 Contractoy ` 3Li Phone } 4 dress R � . TYPE OF WEW WELL RA WELL REPLACEMENT ❑ DESTRUCTION 14_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X nNl�iq%h� wefts DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A ❑ Industrial ❑ Open Bottom Pk Manteca Dia. of Well Excavation Dia. of Well Casing y ❑ Domestic/Private AGravel Pack ❑ Tracy Type of Casing rQ✓e- Specifications FI Public ❑ Other fl Delta Depth of Grout Seal VA 11:5 Type of Grtxui 4� Cir*EmT I I Irrigation VAllilc$.Approx. Depth I I Eastern Surface Seal Installed by WAI- P,An - Repair Work Done Ll Type of Pump H.P. State Work Done_ Well pDestruction ❑ Well Diameter Sealing Material (top 50') /•w-N�l-hit- IN 9 06S Depth Filler Material (Below 501 ---_._ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms 1 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 p FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1-1 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 D3trict. 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: 'h 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.r The applicant ust call for all required iflspections. Complete drawing on reverse side. -s f� _ e Signed X V� Title: PAIS — A I I-L r' (k- Date: 7" q =T T E IT USE ONLY Application Accepted by q Date a Pit or Grout Inspection by Date /� Final Inspection�q Date �G Additional Comments: Mwyl- Zy 77 o flire-S , �j'z_U-. - �jl`s �Yr„)4CG3 )410L klm/lv O Stk 4666781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 r7n,'5ff_ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO (p} / . EH 1a341REV.1/nsI 332Z Q'(10-Sp n2007 EH 1410