Laserfiche WebLink
APPLICATION FOR PERMIT J µ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA 1N �► , <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED- <br /> (Complete <br /> SSUED I q � <br /> {Complete in Triplicate} r,. .. <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 1 <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 // G r Y!fS City 4 t1/O rl� Lot Size p C) PM <br /> Owner's Name S �Iy dei)UNO Address T Y�� SW�S 7Phone <br /> Contractor k,1E;L- Address License-No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT„❑_-.v .•Y..+- DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ +� r_ OTHER ❑. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE` <br /> FOUNDATION- AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private _❑ Gravel Pack ❑ Tracy Type of Casing 7 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ; <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done , <br /> Well Destruction © Well Diameter Seating Material {top 501 <br /> Depth 5 Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_- -Other <br /> a - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> t•. <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ J Method of Disposal ; <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. &'Length of lines Total length/size <br /> FILTER BED ❑ Distance,to nearest: Well Foundation Property Line <br /> Ot OfO <br /> SEEPAGE PITS X Depth Size Number <br /> SUMPS ❑' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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." I <br /> The applicant must call fo II requiro inspections. Complete drawing on reverse side. r' <br /> SignedTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date — Area <br /> Pit or Grout Inspection Date c� Final Inspection by Date / <br /> Additional Comments: 7��R„'P4, l o;? S 3 1J <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Me teca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> v <br /> FEET DUE T AMOUNT REMITTEa RECEIVED 8Y DATE PERMIT"NO. <br /> INFO �9 ate, CASH <br /> + EH13-24 MEY,I/e 57 <br /> EH 14-26 <br />