Laserfiche WebLink
I <br /> APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HAZE,TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> z .,. :j; (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. 1562 for wail/pump and the Rules and Regulations of the San Joaquin a <br /> Local Health District.. ; <br /> ' " cityr} STOCKTON Lot Size PM <br /> Job Address 415 S. DEL _ <br /> E Owner's Name <br /> KAREN SMITH Address - - - Phone <br /> Contractor's Name WORLD ENTERPRISES kicemrPto. <br /> 265964 Phone 466-0717 <br /> TYPE <br /> Contractor's <br /> WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ T�SYSTEM REPAIR ❑ —.A — OTHER ❑ <br /> I DISPOSAL FLD. PROP. LINE 1 <br />►. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />` AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i FOUNDATION <br /> rr <br />� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 g, <br /> II E <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Dia. of Well Casin <br /> i Type of Casin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack p ❑•Tracy yP g Type of Grout <br /> ❑ Public El Other <br /> # [f Delta Depth of Grout Seal <br /> ❑ irrigation �Approx. Depth� E] Eastern Surface Seal Installed by <br /> Repair Work Done. ❑ Type of Pump <br /> i H.P. State Work.Done <br /> Well Destruction ElWell Diameter Sealing Material [top 501) <br /> Depth Filler Material IBelow 50'1 <br /> I <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION. availabperwithin e200 feet.) <br /> itted if public sewer is <br /> Installation will serve: Residence— Commercial+— Other 1 1 <br /> Number of living units: °' Number of bedrooms �. <br /> �- � Water table depth <br /> Character of soil to a depth of 3 feet: ; No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> i. Distance to nearest: -Well Foundation Property tine <br /> ° I <br /> : s <br /> LEACHING LINE 13 No. & Length of lines Total le:' <br /> Property a tine <br /> FILTER BED <br /> L] Distance to nearest: ' Well Foundation P rtl+ <br /> . SEEPAGE PITS k ❑ Depth Size Number <br /> 4. Property Pro a Line <br /> SUMPS � ❑ Distance to nearest:' Well foundation p 1 <br /> ► DISPOSAL PONDS D <br /> 1 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 grid regulations of the San Joaquin Local Health District. <br /> r 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 /> is 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 fallowing:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's c mpensa- <br /> i tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. E <br /> I. Title: _ SECRETARY Date: 2-28—R-1 } <br /> Signed i <br /> FOR DEPARTMENT USE ONLY I <br /> Date Area <br /> Application Accepted by is <br /> by Deg <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: OF <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 V❑ Tracy 835 63!35 � P Z <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (c/ tziGror� <br /> I, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYHDATEPERMIT'No. <br /> INFO 00 ^�3 C}�-a� <br /> r EH 1324{REV.101831- , f iii <br /> EH 14-28 <br />