Laserfiche WebLink
ly. <br /> I APPLICATION FOR PERMIT <br /> k � <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT Go <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t Telephone'(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> . f . <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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulationsof the San Joaquin <br /> Local Health District.— <br /> 10 <br /> I Job Address /�� t. X""'W�-'r�-�`�-� CityS�C,le_T�14i Lot Size dii2 V5Q0 T PM <br /> Owner's Name &"1 ZT Address Phone <br /> Contractor W/L Sd 1­319ic.0 l-"1P Addressf�ld V N, PA2Ze/2S0-r License No. )3 Phone <br /> TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ # <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL S <br /> f INTENDED USE TYPE OF WELL PROB ECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Ia. of Well Excavatio Dia. of Well Casing \� <br /> _ ❑ Domestic/Private ❑ Gravel Pack cy Type of Casingations <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Do Type of Pump H,P. State Work Done_ <br /> Well ction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth , .Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> available'within,200 feet.}--. - <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. ❑ '��� <br /> Method of Disposal � <br /> Distance to nearest: Well Foundation Pro <br /> + party Line <br /> lk <br /> f LEACHING LINE ❑ No. & Length of lines Tota!length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation ,.Property Line <br /> 4 S :yam }-..�..: <br /> SEEPAGE PITS ❑ Depth's Size Number <br /> k <br /> SUMPS ❑: Distance to nearest: Well Foundation - Property Line-ry <br /> DISPOSAL PONDS ❑ <br /> I 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 /> I rules and regulations of the San Joaquin Local Health District. <br /> agent's signature certifies the following: f <br /> Home owner or licensed a ' <br /> g g g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> I 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 /> 4 The applicant must call for all re aired in5pections. Complete drawing on reverse side. *., <br /> t <br /> t <br /> Signed Title: - _ Date: o <br /> FOR DEPARTMENT USE ONLY ! <br /> t <br /> Application Accepted by Dater " TJ Area <br /> F Pit or Grout Inspection Dateins a Ins tion <br /> y Date <br /> Additional Comments: � � � v1wL, S—k9"$''\ <br /> t ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca '820104.104. ❑-Tracy 835-6385 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE, AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. <br /> + EH 13.24(REV.t/H5) D f� �\! 0/,5.74 <br /> J� <br /> EH 14-28 i•J 0 6 <br />