FIELD DOCUMENTS_CASE 1 - Laserfiche WebLink

Home Browse Search

APPLICAT ON FOR PERMIT N JO AQUIN LOCAL HEALTH DISTRI " 601 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 Has" District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinanoe No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations the San Joaquin Local Health District. I X Job Address 2 3 �R�Cy l3 C V, City R C Lot Size Z PM Owner's Name Address Phone ENG�NF�R s." � S Contractor C .CL AddressLicense No. �.alffmone Z T— 12$ TYPE OF WELL/PUMP: NEW WELL ORE, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJ SYSTEM REPAIR ❑ OTHER ❑ - 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 ri Industrial 430pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wen Casing z ❑ Domestic/Private cKGravel Pack ❑ Tracy Type of Casing C "M;,-7 Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealType of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed biy o Repair Work Done ❑ Type of Pump H.P.Sur 1 o_.1Lp S a a,� 'r'S to n one Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materia! {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence____ irtmercial_ Other ' .ry _e I�1 S+ Number of living units: N_ of bedroom N l J Character of soil to a depth of Water taZedepth SEPTIC TANK ❑ ype/Mig Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal D' a e to crest: dil Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 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 must call for all required inspections. Complete drawing on reverse side. Signed X �aTitle: / Date: 11 FOR DEPART NT USE ONLY Application Accepted by �� qq ��''77 �� Date .� Z.-- C20'6F; a� Pit or Grout Inspection by Date a— Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6085 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK CK 49� RECEIVED BY DATE PERMIT*NO, . EH 13-24 tREV.1 9 NI EH .26