FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR"PERMIT L3 SAN JOAQUIN LOCAL HEALTH DISTRI'�°r pA,�ME%T 1601 E. HAZELTON AVE., STOCKTON, CA REGF.�V�D Telephone 12091 466-6781 PERMIT EXPIRES 7-YEAR FROM DATE ISSUED `? 0 yg89 (Complete in Triplicate) NTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here ��rWd�i7 n is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regul��l�f f�ari Joaquin Local Health District. + 4* f n t 5+Z4/ " %"Z ev-re_PM Job Address j/d r `^oT�� Koct.4� City `� Lot Size Owner's Name '50"k4rr�%w'^s'• C��A• Address 5�� t/?ci tt%% -PleAS 1/5—Y63 -Z 71 134-C 101 Contractor O�C�f'Gts+►dct: l�CF 1-w_cAr491 080 � e_ L;1.3;CGHCGI`rI�[efse No. S'1,Y3 Ph,I1 671~ 7-36 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .0f1b DISPOSAL FLO. PROP. LINE r FOUNDATION 2t7 AGRICULTURE WELL OTHER WELt L/ PITS/SUMPS Zfit s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑/Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Io i+^� Dia. of Well Casing r l�ppm@$tic/Priv e, ❑ Gravel Pack ❑ racy Type of Casing Ue-' Sc-(L ` C pecifications In Public (1'/LOLth�r Delta Depth of Grout Seal `��T�11 t M jYpe of Grou I I Irrigation �Approx. Depth I I Eastern Surface Seal Installed by TPatMnc�Lt .LrCtr �1 �- Repair Work Done ❑ Type of Pump +A�`Z" H.P. State Work Done ! Metl.uJe�f- �S ,�4e3 h)t- Well Destruction ❑ Well Diameter a! Sealing Material (top 501 buy" fit- " z�rn(;a .✓<< , Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I t 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� feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Zn-- Method of Disposal e Distance to nearest: V� Founda Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size , "- c. FILTER BED Cl Distance to_nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth ze Number SUMPS ❑ Distance to nearest: /We-V Foundation Property Line DISPOSAL PONDS ❑ ! 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 shalt 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 e . d inspections. Complete drawing on reverse side. Signed X Title: ra-eco Date: 3 1 e elr ,AP-.11-1 FPR DEPARTM� ENT USE ONLY k Application Accepted by Date Area j Pit or Grout Inspection by Date Final Inspection by Date 2� 3 4 Additional Comments: ❑ Stk 466-6781 O Lodi 369-362f ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 K RECEIVED BY DATE PERMIT'NO" INFO CASH ♦.EH 13.24IREV.1iN5) EH 14-28