FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

V*.04r—= -VIAMo4v UM Mil LINk-t APPLICATION FOR PERMIT 10%io FF—TV1141A LAPIr-- SAN JOAQUIN LOCAL HEALTH DISTRICT FAtD CF-PRO CA 9273 1601 E. HAZE T ON AVE., STOCKTON, CA 1�IC. .` �Oq'177 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address-Al2 i L `�`1 _ RDt) 4- City✓T�i1C.1 D� Lot Size PM �,�, Owner's Name ff(DW IC 5MRir Address IZ1f-f- w WAr,F-11�►�jTbt� Phone Contractor II--I. Address VV MC IUf1<icense No. Phone I452' TYPE OF WELL/PUMP: NEW WELLY WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 14Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other WDelta Shc 4AGA Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump�upm 6i�.P. Ls--�% wAi,4 Z State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') MUNIToe)P4" fil Depth Filler 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length size FILTER BED CI 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 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 f California." The applic t must call for 1 req ired inspections. Complete drawing o everse sideif AAAi&4A4. Signed X Title: r Date: R P SE ONLY �i Application Accepted by Date 1?261� —�l Area Pit or Grout (nspecti y Date Final Inspection by Date Additional Comments: �� ! ►j L/� /� I.W ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca� ❑ Tracy 835-6385 �f/b Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCCK f) RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.i e 5) q / c�- EH 14-28