Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA . } <br /> Telephone (209) 466-6781 rf <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> 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 <br /> made in compliance wrh San_Jl�aquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Districtl 3 J <br /> Job Address City O t Size PM <br /> Owner's Name j Address Phone <br /> �\./ alqAcicensePhone <br /> j <br /> Contracto Adtlress � No Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ICTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ _ :1 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t - 11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V� <br /> ❑ Industrial ❑ Open`Bottom =,❑ Manteca Dia. of Well Excavation Dia. of Well Casing V� <br /> ❑ Domestic/Private '❑ Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> FI Public �� Ll Other { Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth yEastern V.,, Su ce Seal Installed by _ <br /> Reparr Work Done ❑ Typq.0f.Pump _ r HiP:•, State Work Done k MTV <br /> Well Destruction ❑ Well Diameter k t .; Sealing-Material Itop 501 r <br /> Depth�` � � � �' Filler Material;Below 501 � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIVN l-1 REPAIR/ADDITION{.) DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> 1\ #IJ t#j } available within 200 feet.) <br /> Installation will,serve: Residence_ 'domm6rciii l_ Other s <br /> Number of living,units: P {Nurnber•of bedrooms 1,) i,, F�7 <br /> Character of soil to a depth'of�3 feet:' ' 1 r' Water table depth <br /> SEPTIC TANK ' O �Type/"Mfg M *• Capacity r No. Compartments <br /> PKG. TREATMENT PLT.. ❑ '`-" t Method of Disposal •J <br /> �i Distance to nearest: Well +.:' (Foundation — " .Property.Line <br /> LEACHING LINE ❑ No"A Length of lines i �. f Total length/size= M <br /> � ~ 1 ; <br /> FILTER BED" ❑ Distance to nearest: Well ? Foundation --"" Property Line Q <br /> SEEPAGE PITS 11 Depth Size"" Number <br /> SUMPS ❑ Distance•tcrnearest- Well Foundation Property Line /? t <br /> DISPOSAL DSS--E' ­ 1 t[ <br /> 'rel hereby rtify at i hav pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reg.at ons of e S Joaquin Local Health Di1trict. <br /> Home o er or cense agent sign tore certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ a pars n in s h man r to subject to rkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th oll ing: "I ertify t in th rf r ance oft ork for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws f C fornia." J <br /> The ap 'ca u II II i i s o C pl drawing on + rse e. 91 <br /> Signed Title: 7�Ef— Dat2vJUL, <br /> FOR DEPA TMENT USE ONLY <br /> Application Accepted by ° Date , Area_ !� <br /> 12 �Z <br /> Pit or Grout Inspection by � bate Final Inspection by Date ; <br /> Additional Comments: <br /> ❑ Stk 466-6781 IT) Lodi 369-3621 ❑ Manteca a23-7104 © Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> T <br /> FEE AMOUNT DUE AMOUNT REMITTED CK A RECEIVED BY DATE PERMITNO. <br /> INFO CASH <br /> +.EH 13-24(REV.r i y 5) V`�(� <br /> EH 1428 <br /> R <br />