FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 1962 for well/pump and the Rules and Regulations of the Sen Joaquin Local Health District. /J Job Address 7.f hles-> ✓ 141de iClwo // city 1&0/ Lot Size PM Owner's Name ddO.PAItJ Yief,*O 6AA Add. JAn7(7 A� 4$0✓F Phone - A 3 - 214 Contractor BQy'veild !'A/Di✓P// AddressDO,YGy� I✓/•✓ e.?Q tl�License No. Phtme' i �d PE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT.❑ _ DESTRUCTION ❑ PUMP INSTALLATION ❑ -- SYSTEM REPAIR-L7 —Ol'HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS IR Industrial IMIlIfiGPidt, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �yEab ❑ Domestic/Private 19 Gravel Pack M Tracy Typo of Casing - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -� l Type of Grout ❑ Irrigation j�—Approx. Depth ❑ Eastern Surface Seal Installed by /�/n'• Repair Work Done O Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ' " Sealing Material (top 601 Depth_ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted 9 public sewer is available within 2DO feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of wil 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. A 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 ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, note laws, and rules and regulations of the Sen Joaquin Local Health District. Home owner w licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, 1 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,1"it employ persons subject to workman's compense- tion laws of California." _ The applicant �must call for all required irspectlons..Complate drawing onverse side. Signed X I wt/v`�T'y K . v_ ""`^J�'� Tide: I'-uN``iD'�A� Date: j/ �-`, C FOR DEPARTMENT USE ONLY _ Application Accepted by / . G-�a�� Date r �S A. 911 /ice Vtl Gtr,7 /%�� -' ilA! Pit or Grout Inspection fly Final inspection by / Data Additional Comments: //�/��/!✓�i 5(i�0on�r.�ALI�aO: ,l,/!��/71�PcDf�d ,C'rfD� 5?AC170/✓�/9 2A9- 9�/�--�3�1f ❑ Stk 496-Ml ❑ Lodi NS-3921 ❑ Manteca 923-7104 O Tracy 835.8385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K s RECEIVED 6Y DATE PERMIT N0. INFO CASH ♦ EH 1}7t IREV.�/ear FH 1124