Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA - - Q <br /> . Telephone 1209) 466-6781 <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 with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> "Local Health District. .. - .. " <br /> C Job Address ,� — City Lot Size 2a6.)( F':Z PMI <br /> i '�,,n /� � <br /> Owner's Name /�'/�'1 �!-�i /Q�C Address ' - Phone-T-44Z <br /> T -f- <br /> Contractor ~(�(� r l �"` -License� Address fl License No 'Phone <br /> TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION - T.- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ n OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V- DISPOSAL Fl—D:— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> /I•NTENDED'USEE-OF WELL PROBLEM AREA CONSTRUCTIq SO SECIFICATIONS <br /> O�Industrial El Open ❑ Manteca Dia e I Excavation r Dia. of Well Casing <br /> -- <br /> [ Damest--b- ic/Private 0 Gravel'Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Appro th El stern ce Seal Installed by <br /> Repair Work Done ❑ T Pump H.P. State Work Done 0(j <br /> f Well Destruction Well Diameter Sealing Material (top 501 G <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> ", available within 200 feet.) <br /> k Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms-. <br /> Character of soil to adept of 3 feet: , Water table depth <br /> SEPTIC TANK �Type/Mfg Capacity -. No. Compartments <br /> PKG. TREATMENT PLT. ❑ # Method of Disposal <br /> Distance to nearest: Well Foundation ' Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER :BE ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ' Deptrh , „• Size Number . <br /> SUMPS ❑ Disf'ance to rieareif "CNell �-"" Foundation � 'T Property Line <br /> DISPOSAL PONDS ❑ 1—...—�,. - �.�..--� ,. _-.�,.. . 3 .; �.� •� ..�-s <br /> hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ' 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- <br /> tion laws of California." <br /> The applicant must call fo all requi d inspections. Complete drawing on reverse side. (]- <br /> � <br /> Signed X U/� �P _ Title:'r � ��( Dater­74� "" le- 15 <br /> R. <br /> FOR.DEPARTMENT USE ONLY <br /> Application Accepted by f Date 3- `' Area <br /> i � f I <br /> Pit or Grout Inspection Date Final Inspection by L �te--_d.,,d,,,,Sr Date <br /> Additional Comments: �+T l a ^ l s . yZ fl <br /> ❑ Stk 466-6781 © Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Envir nmenta Health Perfmit/Servic/gds 1601 E. 7azelt6nf�Ave., P.O. Bo 2009, Stk., CA 95201P� } <br /> l Jt fn 4 b � �4 0 f CL`+--e- l�/•L C_ tC� , V E � - 6,/.2 A )S f' x <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 43"24/REV.t/a57 <br /> EH t426 <br /> . L <br />