Laserfiche WebLink
APPLICATION FOR PERMIT • ' <br /> SAN JOAO,UIN LOCAL HFEALTH DISTRICT <br /> -1601 E. HAZEL T ON AVE.,1 STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete'in Triplicate) { <br /> Applicahetion is hereby made to the San Joaquin Local Health District for a permit to construct ad/or install the work herein described.This application <br /> Rules and Regulations of the SanJoaquiis <br /> made in compliance with San Joaquin County Ordinance.No.549 for sewage or No. 1862 for well/ and tn <br /> 'Local Health District. <br /> � r' J.. � <br /> ` Q C`! -1J VLot Size P PM <br /> Job Address—�1 x , City <br /> 6� <br /> y��y ,~ Phone t <br /> Owner's Name'TD � Q NfiG' S I C Address � � 1 ►y�V <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUM NEW WELL 13WELL REPLACEMENT LJ DESTRUCTION <br />�. PUMP INSTALLATION El SYSTEM REPAIR ❑ OTH ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE -TYPE OVWELL—=-- w--PROBL-EM-AREA-�;T--CONST-RUCTION-SPECIFICATIONS' <br /> ❑ Industrial F1OpenmBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal YP <br /> ❑ Irrigation --Approx. Depth 11Eastern Surface Seal Installed by ; <br /> Repair Work Done Ll Type of Pump H.P. State Work Done <br /> # Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter 9 <br /> "Depth - Filler Material (Below <br /> TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> rented if public sewer is <br /> ava1 <br /> Installation will serve: YJResidenceli— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth,of 3 feet: Water,table depth <br /> SEPTIC TANK L1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> rz <br /> Distance to nearest: Well Foundation Property Line <br /> #j <br /> :t <br /> LEACHING LINE C3No. & Length of lines Total length/size - <br /> --Pra Line <br /> FILTER BED ❑ Distance to.nearest:. ,Well - - ;,Foundation--- <br /> FILTER <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to,nearest: Well Foundation -,�Prop"-Line-=--­--- <br /> DISPOSAL <br /> rop"-Line- -­---DISPOSAL PONDS ❑ <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cbdnty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> ollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the f <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> 1 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 applica call for a required ins ns. Complete,drawin feverse side. <br /> ''1 4'* 11� Date: <br /> Signed e' _ <br /> �QR DEP RTMENT-USE 6f11LY <br /> Area <br /> CZ- <br /> Application Accepted by �'� � ` s - <br /> l <br /> Pit or Grout Inspection by Date Final Inspection464&� Date Z <br /> Additional Comments: <br /> [7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 El Tracy 835 63rd <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f iRECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNTrDUE AMOUNT REMITTED, CASH <br /> INFO <br /> S <br /> i + EH 13-241AEV,i/851 <br /> N 1428 <br />