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 <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. <br /> Jab Address /7- nI R� 7/c T1�r�la Cityt&k C19LOA) Lot Size AD 192CESPM 0. <br /> Owner's Name OI IF Address Phone <br /> ContractorMUOD ' drabs ' ,5 R(2--d J1 License No.,&(0 ,} Phone <br /> TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ A(Y) ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES 1,00 r�f�"n, r�r—DISPOSAL FLD. ) � PROP. LINE �(v�_�O �]� <br /> FOUNDATION � AGRICULTURE WELL 1000 OTHER WELL PITS/SUMPS A 1 r�,ll� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal " Type of Grou <br /> &2771,07A� <br /> ❑ Irrigation Approx. Depth <br /> �v❑.,,Eastem Surface Seal Installed by <br /> Repair Work Done CJ Type of Pump S(,012) H.P. State Work Done N Ilk) <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ 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 ❑ 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 /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth = Size Number <br /> SUMPS ❑ Distance to nearest: `- Well, --- Foundation- Property Line <br /> DISPOSAL PONDS ❑ y <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..„" I. <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, I 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 laws of California." <br /> The applicantcall for all required inspec yon . Complete drawing on rev rse side. <br /> Signed X� �^ Title: .2 474Z / r t Date- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r Area vU <br /> Pit or Grout Inspection Date �'7 Final Inspection by ` C ADate .� <br /> f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT-REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO CASH +�y -1 <br /> + EH 13-24(REV.1/85) {v< �0 -.U� ��-��-^ a -;X - D7 - 3� <br /> EH 1128 9 7 3 Q <br />