Laserfiche WebLink
i..0�_ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Regulations of the San Joaquin <br /> Local Health District. f/ .✓/ Q�[7 / <br /> Job Address � 1T4iJ�'f `� ` ��— Cit Lot Size� ���Z-�Z PM <br /> r � <br /> 44� <br /> i <br /> Owner's Nam I Address GC� Phone 7 a 7 <br /> L . Contract <br /> Lb Address d r Licerise No32-�1 Z etc Phone k_sIOS <br /> 7TYPE OF WELL/PUMP: NEW WELL 1:1WELL REPLACEMENT ❑ DESTRUCTION Ll - <br /> PUMP INSTALLATION L) SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO EAREST I SEPTIC:TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ IndustriaF O Open Bottom *.� El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack's ❑ Tracy Type of Casing Specifications <br /> 17 Public ❑ Other `� -❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___-APprox. Depth ❑ Eastem, Surface Seal Installed by <br /> s. � <br /> Repair Work Done LlType of Pump`" - H.P. State Work Done_ J <br /> Well Destruction ❑ Well Djameter;i. = Sealing.,Material (top 501 j <br /> Depth iller-Material (Below 501 <br /> TYPE OF SEPTIC WORK NEW INSTALLATION O REPAIR/ADDITID V DESTRUCTION C1 (No septic system permitted if public sewer is <br /> 1 Q aailable within 200 feet.) <br /> Installation will serve: Residence— Commercial Other � '`�'""^� <br /> Number of living units: Number of b rooms f 000 <br /> Character of soil to a depth of 3 feet: - <br /> Water table depth r <br /> C>t3• Type/Mfg Capacity `�Q.. No. Compartments <br /> TREAT ENT PLT- F] r < Method�o-f~Dlisposal <br /> Distance to nearest: Well /60 Foundation �XQ Property Line1 <br /> t <br /> LEACHING LINE P'-No. & Length of lines — y Total length/size X Z <br /> FILTER BED ❑ Distance to nearest: Well 100 Foundation (S f1_-� Property Line <br /> SEEPAGE PITS W""Depth-.. Size 33 Number <br /> r <br /> SUMPS_ ❑ Distance to nearest: Well /.'fin, Foundation _/,0 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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, l 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 lays of California." <br /> The applicant must call for all qui d inspections. Complete drawing on reverse side. <br /> Signed X Title: w , 1 Date:--!7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,1 G - Date- . - fo. Area <br /> T l O <br /> �t <br /> or Grout Inspection by <br /> ate '` ina1 Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CAS H <br /> + EH13-241REV.s/851 3� <br /> EH 14-26 <br /> x <br />