Laserfiche WebLink
rt <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <br /> Telephone.(209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ce No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County ordinance 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 /> Local Health District. 1 <br /> f 77 5A ,,,,,,,,,,, //////'''''' LoPM <br /> ` ����""""�� t Size City � <br /> Job Add 3 <br /> Phone <br /> Address <br /> Owner's Na a ��ffTO <br /> E, License N a Pho <br /> Contractor — Address i <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SEWER LINES DISPOSAL,,'FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> FOUNDATION _- -- . . ----.�-^^" k <br /> CI ICATIONS <br /> 4 TYPE OF WELL PROBLEM AREA CONSTRUCTIO s i <br /> INTENDED USE --- Dia.f�f Well Casing <br /> i❑ Open Bottom ❑ Manteca Dia e I Excavation <br /> ❑ Industrial Type of Casing 5peciiications <br /> ❑ Domestic/Private ❑ Gravel Pack Q Tracy yp Type of Grout <br /> .�Fl Other a to Depth of Grout Seal # <br /> F1 Public Surface Seal installed by <br /> 11 Irrigation i Appr pth L i Eastern } <br /> I-- H P State Work Done <br /> Repair Work Done ❑ of Pump <br /> Well Des1ruc ❑ Wel! Diameter Sealing Material (top 50'1 i <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t_l-.DESTRUCTIO TaNailable!wthine200 feet.), rf public sewer is <br /> l Other_�--- <br /> instill ation.will serve: Residence Commercial " <br /> Number of living units: Number of bedrooms ; Water table depth <br /> Character,of'soil to a depth of 3 feet: No Compartments <br /> i ❑ Type/Mfg Capacity <br /> SEPTIC TANK vk <br /> J f Method of Disposal <br /> PKG, TREATMENT PLT. ❑ t* •f,..'1 r ` <br /> Foundation Property Line <br /> Distance to nearest: Well - R <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance totnearest: Well <br /> Foundation Property Line <br /> Number <br /> SEEPAGE PITS I I Depth <br /> Size <br /> I SUMPS Ll Distance to nearest: Well <br /> Foundation Property Line <br /> !— <br /> i DISPOSAL PONDS ❑ <br /> I nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I,have prepared this application a <br /> rules and regulations of the San Joaquin Local Health District. <br /> a Home owner or licensed agent's sigrformance of the work for which this permit is issued, l shall not <br /> nature certifies the following: "I certify that,in the pe <br /> ring or <br /> k <br /> employ any person in such manner as to become subject to workman's compensation laws ss California." ploy cersons`subj ct to woorkman'rscopensa <br /> certifies the following:'"I certify that in the performance of the work for which this permit is issued,t Shall empty p ' <br /> tion laws of California." <br /> Theapplicant ust call for all required inspections. Complete drawing,-on r arse side. <br /> Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY nr:r- <br /> ``} r <br /> Date I—r�y�� — e ) <br /> �3 M <br /> Application Accepted by <br /> Date Fina Inspection by; <br /> i Pit or Grout Inspection by <br /> 1 Additional Comments: " <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-., P.O. Box 2009, Stk., CA 95201" <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. <br /> FEE AMOUE­ <br /> EH <br /> AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-241REY. <br /> ins) 6 <br /> 14-2e - <br />