Laserfiche WebLink
APPLICATION FOR PERMIT <br /> :E SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEr_TON AVE., STOCKTON, CA <br /> II Telephone (209) 466-6781 1 , <br /> I; PERMIT EXPIRES 7 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 compliancelwith 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. n Y}yfi <br /> At <br /> c� 1 <br /> Job Address O L G G <br /> _ City �of Size J1D `_-y.Zo.0PM <br /> Owner's Name �/ Jll �/�� !f tllress /�� Phone 94`� G <br /> n <br /> r � <br /> ContractorAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR _ALINE <br /> .I FOUNDATION RICULTURE WELL OTHER PITS/SUMPS <br /> +r <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCT CIFICATIONS <br /> ❑ Industrial jf ❑ Open Bottom F-1 Manteca Di ell Excavation Dia. of Wel! Casing + <br /> ❑ Domestic/Private`. LJ Gravel Pack ❑ Tracy Type of Ca Specifications <br /> ❑ Public IJ Other ta. Depth of Grout=S. Type of Grout <br /> ❑ Irrigation I J4pprox. D ❑ Eastern _ n, Surface Seal Installed by �/- <br /> Repair Work Done ❑ Type ml. H. <br /> P. State Work Done <br /> Well Destruction li ❑ ell Diameter Sealing Material (top 50') <br /> Depth Finer Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is n <br /> i� available within 200 feet.) �J <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 11. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT'PLT. ❑ Method of Disposal <br /> Distance to nearest: Well } Foundation Property Line <br /> LEACHING LINE :I ❑ No. & Length of lines Total length/size <br /> FILTER BED S ❑ Distance to nearest: . Well rFoundation Property Line <br /> ;I <br /> SEEPAGE PITS ❑ Depth _ Size t Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 a licant must call for all requir d inspecti ns. Complete drawing on reverse side. <br /> Signed Title: _ Date: <br /> �' FOR DEPARTMENT USE ONLY <br /> Application Accepted by 19 <br /> Date J `:?e:'—977 Area © J <br /> iif J <br /> Pit or'Grout Inspection by Date Final Inspection by Dateo�� <br /> Additional Comments: Do <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 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 96201 <br /> T <br /> k <br /> INFOFEE AMOUNT DUE``,, AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> + EH 13241REY. /a 5} C�V �� Ip <br /> EH 14-26 a iI ` ®{700 <br />