Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4_ 1601 E. HAZEL T ON AVE., STOCKTON, CA - <br /> 1 ; Telephone (209) 466-6781 <br /> E PERMIT EXPIRES tYEAR FROM DATE ISSUED <br /> i (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. 186 <br /> Local Health District. 2 for well/pump and the Rules and Regulations of the San Joaquin <br /> t <br /> ,lob Address �65 5 <br /> C Cit � � <br /> Lot Sizev7� �fJ PM <br /> Owner's Nam qr <br /> Address <br /> ZO Phone <br /> I Contract r Address ' <br /> TYPE OF WELL/PU License No. �z�- Phone <br /> NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ <br /> E DISTANCE TO NEAREST: SEPTIC TANK, OTHER 1-1k <br /> -� SEWER.LfNE5 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION -� AGRlCULTU ELL - <br /> "INTENDED USE- ----.:.TYPE OF-WELL­ PROBLEM A-' OTHER WELL PITS/SUMPS f <br /> ❑ Industrial CONSTRUCTION_SP.ECIFICATIONS <br /> ❑ Open Bottom ❑ eco Dia. of Well Excavation <br /> ❑ Domestic/Private Dia. of Well Casing ` <br /> ❑ Grave! Pack Trac <br /> f'1 Public y Type of Casing <br /> Other ❑ Delta Specifications <br /> I i Irrigation Depth of Grout Seal <br /> --Ap Depth ( l Eastern Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ T <br /> of Pump H P <br /> Weil DestructionState Work Done, <br /> Well Diameter Sealing Material {top 50') <br /> .1, <br /> Depth Filler Material {Below 501) <br /> TYPE OF PTIC WORK: NEW INSTALLATION Im <br /> REPAIR/ADDITION I ] DES7RUC7tON I 1 (No septic system permitted if:public sewer is <br /> Installation will serve: Residence Commercial Other available within 200 feet:) _ <br /> � _ '�� <br /> Number of living units: _,L- Number bedrooms / <br /> w ! <br /> Character of soil to;a depth of 3 feet: ` <br /> 11 r <br /> SEPTIC TANK L7 Type/Mfg e� Water table depth <br /> Capacity d&G <br /> PKG. TREATMENT PLT. C7 No. Compartments <br /> / +7 . .i Method of Disposal i- <br /> �`` Distance to nearest:' well 5� - i <br /> Foundation D <br /> --��_ Property Line 2 <br /> LEACHING LINE { <br /> No. & Length of lines <br /> FILTER,BED' Total length/size <br /> ❑ Distance to nearest: Well JAG _ - f <br /> Foundation Property Line <br /> SEEPAGE PITS I i Depth Size <br /> SUMPS Number <br /> Distance to nearest: Well 0 <br /> DISPOSAL PONDS ❑ Foundation�1l -� Property f=ine 5- <br /> I <br /> 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, <br /> rules and regulations of the San Joaquin Local"Healfh DIJI ict."" ' "" - .--- <br /> Home owner or licensed agent's signature certifies the following: Y pe ___.. <br /> "1 certify that in the rformanc'e of the'work for which this permit is issued, l shallrnot a <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 •i <br /> certifies the following: "1 certifythat in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." P ❑ y persons subject to workman's compensa- <br /> The applicant gust call for all required inspections. Complete drawing on reverse side.IF <br /> F <br /> SignedX-111 <br /> Title: Date: ® "��dr 9 " <br /> FOR aEP RTMENT USE ONLY � <br /> ;A,ion Accepted by <br /> f� Date � Area <br /> Ihspection by <br /> �`'15ate Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED RECEIVED BY <br /> CASH DATE PERMIT NO. <br /> +.EH 13-24(REV.F i tt 51 �0 <br /> EH 14-2g <br /> s <br />