FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT OW L3 y5 SAN JOAQUIN LOCAL HEALTH DISTRICT P py M NT 1601 E. HAZE'LTON AVE., STOCKTON, CA REC;F Telephone 52091 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (llwa 2 tigg3 (Complete in Triplicate) NAL H`cALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here ��. �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 i 1a tJoaquin Local Health District. fl Job Address 10 f1K" Qoctd City 54,-,41JMLot Size �y a-rCPM Owner's Name Snuf�C R.�[LL Car Address ✓fir "`L/"iQ -//s—Y6 3 z711 /� J Contractor o�C--re LLA1dw kr I tc yea pf� t LA. C0WOrq LC�se No. 413`13`1�� Pho��6 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ ' j DISTANCE TO NEAREST: SEPTIC TANK ��,�,, SEWER LINES 3a� DISPOSAL FLD. PROP. LINE L� r` FOUNDATION �� AGRICULTURE WELL OTHER WELL /_0 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 112,5- i;" Dia. of Well Casing Z r Ytc h p©m $tic/Priv e ❑ Gravel Pack ❑ racy Type of Casing 114' SC-16L c{n pecifications o�i.tc+�r n�u.erf j�esf ('1 Public n�iiothpr Delta Depth of Grout Soal n b,- Cl�rMl ,,;1� ype of Gr N�e Gem I I Irrigation L�Approx. Depth I I Eastern Surface Seal Installed by. &tV.wAd~W.1Lk1" 1,Ct Repair Work Done ❑ Type of Pump Acxe_ H.P. State Work Dorrj�1.5 t AiCA.r: dil e5 CC,,i5j�riky Well Destruction ❑ Well Diameter_ Sealing Material (top 501 a&L& fie' /� & Depth 44 Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l] REPAIR/ADDITION l.1 DESTRUCTION l 1 (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 1 SEPTIC TANK ❑ T ~ ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ " Method of Disposal Distance to nearest: Founda ' n Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ze Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Di1trict. . "-)k 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 re"d d inspections. Complete drawing on reverse side. s L / 31131-43 Signed X Title: rp eV �cY Date: v—_C_4;L"a r-� 9 37 FOR DEPAR MENT,USE ONLY 29/� Application Accepted by /] Date Area Pit or Grout Inspection by Date 13 �Cv Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. +.EH 43.24 1REV.t i x 5i EH 1428 0 -1 -ls