Laserfiche WebLink
APPLICATION FOR PERMIT S <br /> P1+ . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781, <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> x tiGO �e ' �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:TNs 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 /> Job Address � City C of Size PM <br /> l[Ei Owner's Name _4/'z 4 t�4 nJ YA+'nfid4t I� S—n �/ A & /l Q V,(if.C.P Phone <br /> Contractor Address License No. Phone o <br /> ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT I <br /> PUMP INSTALLATION ❑ k SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 'i <br /> i <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> II INTENDED USE TYPE OF WELL PROBLEM :k CONSTRUCTION SPECIFICATIONS „ <br /> f ❑ Industrial ❑ Open Bottom ❑ teca 1 Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing Specifications' `\ <br /> ❑ Public LlOthe 1:1 Delta I Depth of.Grout Seal Type of Grout A <br /> %❑ Irrigation �4pp,ox. Depth ❑ Easiern Surface Seal Ins tailed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter �` � Sealing lMaterial Itop 501 <br /> Depth '" Filler Material IBelow 501 <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-El DESTRUCTION {No septic system permitted if public sewer is <br /> F ` available within 200 feet.l-3 <br /> Installation will serve: Residence Commercial_ Other =' ^ <br /> t Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: s Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-- l • ` " No. Compartments <br /> PKG. TREATMENT PLT. ❑ - �f Method of Disposal <br /> Distance to nearest:- WeIE <br /> 'i+ Foundation Property Line <br /> a _ <br /> LEACHING LINE ❑ No:-&"Length of liries' -- -- "�"" � ___ Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well l Foundation Property Line <br /> SEEPAGE PITS I-T, <br /> Depth Size �E° Number <br /> SUMPS ❑ Distance to nearest: Well 41 Foundation—,Property Line <br /> DISPOSAL PONDS ❑ ` <br /> F 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> k, 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." k <br /> a <br /> Thea licant mus til for.0II req inspections. Co a wing on reverse side. <br /> 4 �7 <br /> FLigned X Data: ._ <br /> FOR DEPARTMENT USE ONLY <br /> r Application Accepted by Date "� Area <br /> E s <br /> I Pit or Grout Inspection Date ' Final Inspection by��r_ Date <br /> b / <br /> Additional Comments: ao 7,4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LI-Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/ServiclIes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH'13-24IREV.till 5) r �-o0 -( <br /> `p <br /> EH 14-26 <br />