Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> E. {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. �3� •�9 <br /> Job Address 5Q t Size�`30 PM <br /> CkW ,9,5~ <)7 <br /> Owner's Name Address /I _Lj -Snli4ilJ Phone <br /> /W,,fra/J/�urnP su,oph y <br /> Contractor �"ftl G Address c5- /Q�ed ,Cjf?�[I License No.c�-�-S Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL 20 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ] SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �s5'J `f- SEWER LINES /50'7- ..— DISPOSAL FLD-Xa2- PROP. LINE <br /> FOUNDATION s2 AGRICULTURE WELL 4-1J,-0THER WELL PITS/SUMPS O•c1� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. a <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation // Dia. of Well Casing Z" <br /> .Domestic/Private Gravel Pack ❑ Tracy Type of.Casings -=—Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal J Type of Grout <br /> ❑ Irrigation __—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH.P. — State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 [� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Od` <br /> available within 200 feet.) r <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:-C]"..,- ��..—.`_ _ * Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> l LEACHING LINE. " ❑ No. & Length of lines �' Total length/size w� } <br /> FILTER BED ❑ Distance to nearest: WellFoundation Property Line <br /> i <br /> SEEPAGE PITS r ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well ° 3Fo nu tlarion ' Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> employ any person in such manner as to become subject to workman'ss compensation'laws of California."Contractor's hiring or sub-contracting signature <br /> k 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 call for all re ad ins c' ns. Complete wing onr�rse side. ; <br /> Signed ' Title: Date: <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date Area O <br /> Pit &nal <br /> nspection by Date Final Inspection by Date <br /> j <br /> Addmments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 <br /> --FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PpRMIT'"NO. <br /> INFO / - �Jru //� +. ry <br /> + EH 13-24 IREV.t i e 51 <br /> EH 14-28 <br />