Laserfiche WebLink
• APPLICATION FOR PERMIT r: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` e <br /> 1601,E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , <br />-� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ' <br /> Job Address is— A161 ffi L�)nee 1 G 4 C City Lot Size PM <br /> `Owner's Name" 626. Address o7 Al &m S.T. 44 phone <br /> ... �.,,. _ .. Cir - f <br /> Contractor 0*4r/oju Address O License No. q OSo=. Phone -Sr6o <br /> TYPE OF WELL/PUMP: NEW WELL IR WELL REPLACEMENT ❑ DESTRUCTION ❑ Horyt��,va WEA& <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �'� i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /O Dia. of Well Casing -2 r 4 <br /> ❑ Domestic/Private iX Gravel Pack ❑ Tracy Type of Casing 4 a Specifications c\� <br /> ❑ Public uxra `❑ Other ❑ Delta Depth of Grout Seal x 2 1 Type of Grout <br /> ❑ Irrigation W ---Approx. Depth ❑ Eastern Surface Seal Installed by E <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 2 Well Diameter " Sealing Material (top 501 <br /> Depth O Filler Material (Below 501 <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation serve: Residence_ Commercial-_ Other <br /> Number of living uni Number of bedrooms <br /> Character of soil to a depth o t: er table depth <br /> SEPTIC TANK ❑ Type Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well oundation Property Line <br /> LEACHING LINE ❑ No. & Length of Ii <br /> Total length/size <br /> FILTER BED ❑ Distance arest: Well Foundation erty Line <br /> SEEPAGE PIT5 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DI AL PONDS ❑ <br /> 1 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 <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 I <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 9 <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 mus all for all required i ctions. Complete drawing on reverse side. / <br /> Signed X Title: Date: .3/ tZrq 7 <br /> a <br /> ' PA 4VE ONLY <br /> Application Accepted by Dated/ �_ Area <br /> Pit or Grout Inspe on CQ ne, Data 0-5- Final Inspection by Date <br /> Additional Com nts: <br /> ❑ Stk 466-6781 ❑ Lodi 1369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6385- Return all copies to:�Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS RECHVED 8Y :DATE PERMIT`NO. " <br /> a EH 1&241REVA7/851 -3 —79 <br /> EH 13-29 <br /> f <br />