Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 SEP 4 9987 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ENVIRQMENTAIw HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <br /> Application is he+eby 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.'] <br /> 77 7 <br /> Job Address / —719 N- y Ceeelc •City Ga Lot Size PM <br /> Owner's Name " LOddress Phone <br /> I• <br /> Contractor Address 7) 45 frs7s'C �//&ense No. 33�---�f'hone331;1 <br /> TYPE OF WELL/PUMP:�,,,,�.._��NEW.WELL WELL REPLACEMENT L] DESTRUCTION E3 <br /> o PUMP INSTALLATION ❑— «° SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO_NEAREST:_ SEPTIC TANK,. SEWER LINES DISPOSAL FLDJW I' PROP. LINE3�� <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL ,PITSLSLIMPS pro f'"�µ <br /> INTENDED USE TYPE OFWELL { PROBLEM AREA CONSTRUCTION SPECIFICATIO <br /> ❑ Industrial Open Botiom .❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> Domestic/Private .-0 GravelRack, ❑ Tracy ;Type of Casing �! ~�23 Specifications <br /> r A. n <br /> FI:Public ❑ Other +�`�. ,� ❑ Delta w# Depth of Grout Seal �O Ty e of Grout q� ,3! <br /> i I jlrngation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Hone 0 Type of Pump 3 H.P,'a State Work Done <br /> Well Destruction ❑ Well Diameter s Sealing Material (top 501 <br /> Depth cy-�[7 i Filler Material (Below E0, <br /> s TYPE OF SEPTIC WORK: NEW INSTALLATION I IC REPAIR/ADDITION- I DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> r^x � available within 200 feet.) '. f <br /> Installation will serve: Residence_ Commercial's Other= <br /> Number of living units: Number of bedraoms <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. ❑ } Method of Disposal ' <br /> / Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines' Total length/size <br /> y. <br /> FILTER BED ❑ Distance to neares ell Foundation Property Line <br /> _SEEPAGE PITS I I Depth. Size Number.. ",_,I <br /> SUMPS LlDistance 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: J certify.,that_in the performance.of the work.for which this;permit is issued,•I shall not . <br /> employ an "-°" " <br /> p y y person in such manner as become subject to workman's compensation laws of California."Contractors hiririg�ar"sub-contracting'srgn2tur� <br /> w 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 must call II re wired inspections. C plate drawing on reverse side. <br /> Signed X N� d bate: <br /> 16-.11 "Ov`mow FOR DEPARTMENT USE ONLY <br />..r wa Application Accepted by p .Date Area ® <br /> Pit r Gro Inspection by , Date I Final Inspection by Date ' <br /> r, <br /> n Yv <br /> Additional Comments: y <br /> r'❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6485 <br /> Applicant - Return all copies to: Environmental-Health-Permit/.Services 1fi01.,;V. Hazelton Ave., P:Q..�ox-2009, Stk.,-!CA.FEE <br /> ,95201,w <br /> INFO AMOUNT DUE AMOUNT REMITTED CCASH s t '"RECEIVED BY DATE PERMIT'NO. <br /> + EH1 <br /> 3-241REV.liMSf A5- 4 O b(xo <br /> EH 14-2e � <br />