FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

J APPLICATION FOR'I.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. n� w 1 t� Job Address R R r Q + H1'7 m-wA S City &66e A Lot Size PM Owner's Name cJCt V l ��"n GO{ZP Address J 2 LS S TO 2C M&L Phone(�/S �.- ;�- n _ t a� nn1 i�,1J (may Contractor GRI�:►aOLtrr L2 tL-�t. Address �$D t lKE L4 WJE !e+dcQVnse No. i/3`/3Y3 Phoneme �S TYPE OF WELL/PUMP: NEW WELL 15a WELL REPLACEMIENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl 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 CX ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well:Excavation / Dia. of Well Cas' g y itJc-"t� ❑ Domestic/Private �d Gravel Pack ❑ Trac T' of Casing ' OZD Tracy Type gy� specifications _ ❑ Public " (o ..t I ISI- M��J�F60Ud�❑ Other ❑ Delta Depth of Grout Seal Type of Grout - "��/ n I� 1N WELE. �Approx. Depth ❑ Eastern Surface Seaf installed by S/ f F!c l�2t L4-7�lJC, Repairs WorSone 1:1 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Fitter Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PETS Cl 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 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 applicant7 ca 11 for SII req nion Complete drawing on reverse side. Signed X '4� _ Title: Date: z it USE NLY Application Accepted b Date ! —_,2—_,241 � Z " 7-Area _ Pit or Grout Ins ti y Date Final Inspection bby¢ Date Additional Comments—�" L122! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 83546385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1FEE AMOUNT DUE AMOU(N'T�REMITTED CASH CK RECEIVED BY DATE QPEERjMIT NO. FH i3-24 IREV.i•esi 3 EH 14.26 3St� cif• ��p / _rf1 / a',