Laserfiche WebLink
F <br /> I <br /> E APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � //—7 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i"Fg, <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 Ryles and Regulations of the San Joaquin <br /> I :`Local Health District.err <br /> Job Address h0 90 R. y�_J City • ""'� "` Lot Size V u PM <br /> i Owner's NameLLI�ddress v-"-�/ Phone b J Z +� <br /> Contractor Address License No. Phone <br /> i <br /> TYPE OF WELL/PUMP_:a. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ` . PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> ` Depth Filter Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> I Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms m <br /> } I' <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 /> s Distance to nearest: Well Foundation Property Line <br /> r' <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size �! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� <br /> ' SEEPAGE PITS. 3 °.Depth Size . Number <br /> 51lMPS �� t� E-­Dttistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS a ,❑.sok Yom ` ¢ t ' <br /> I hereby certify that I have prepared this applicatiornand that the-work will be done-in accordance with San Joaquin county ordinances, state laws, and <br /> Imo. , .rules and.regulations.of,the San Joaquin Local Health District. <br /> Home owner o►licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject.to workman's corilpensationgaws ofKalifornia."Contractor's hiring or sub-contracting signature <br /> t certifies the following: "I certify that in the performance of.the work for which thi's perm`is issued, I shall emplby persons subject-to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all req6i Pinspections. Complete drawing on reverse side. <br /> Signed Title: __ Date: <br /> o `F DEPARTMENT USE ONLY <br /> 51/ <br /> Application Accepted byfl, — Date �� 6Area O <br /> Pit or Grout Inspection by Date Final fispection-by Date <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385, <br /> I Applicant - Return all copies.to iEnvironmental Health Permit/Services 1601 E. Hazelton Ave.;P,:O. Box 2009, Stk., CA 95201. <br /> I - <br /> -"FEE 7AM01JNT-0UE—"AMOUNT R€MISTED ` "CK RECEIVED BY DATE PERMIT NO. <br /> INFO -r <br /> a EH 13.24 4REV.1/3 51 <br /> EH 1¢281fO��/ �.S l3S A <br />