Laserfiche WebLink
J APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the SnC oaquin Local Health District for a permit to construct and/or install the work herein described. This <br /> made in compliance with San JoaquintY <br /> Local Health District. LID �"I-e� PM ^ <br /> ^^�� Q �z' "T b City jEi e4 10n- Lot"Size `f V <br /> .J it 2- �7�}� i <br /> Job Address Q 3V J f <br /> �/ erne Phone mac= <br /> Owner's Name Va ��rmu+a ee Address 2 <br /> �q t� <br /> U Address <br /> d_ [1 0. e--License No. kb-o5 Phone f <br /> Contractor WELL REPLACEMENT ❑ D ESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL OTHER ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR PROP. LINE <br /> LIo SEWER LINES DISPOSAL FLD. ��1PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL L PROPI MPS <br /> OTHER WELL <br />` FOUNDATION — � s <br /> ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> INTENDED USE TYPE OF Ww ti <br /> f Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications ///��� - <br /> Gravel Pack ❑ Tracy Type of Casing K ' <br />{ ( <br /> Domestic Private �a <br /> Type of Grout <br /> f� Other ❑ Delta Depth of Grout Seale-� <br /> f'1 Public Surface Seal Installed by <br /> I Irrigation Approx. Depth l I Eastern H.P. State Work Done _ <br /> _�- <br /> f Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> ( Well Destruction ❑ Well Diameter Filler Material )Below,50'1 <br /> f Depth \(1 <br /> TYPE OF SEPTIC WORK: NEW lIlSTALLATION l;l REPAIRIADDITION l 3 DESTRUCTION I I aNailable'wi within 200 feet.) if public sewer is <br /> installation will serve:! Residence— Commercial, Other ---- <br /> Number of living units: Number of bedrooms A Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments ' S <br /> T e/Mig ' Capacity " <br /> I SEPTIC TANK Q Type/Mfg Method of Disposal <br /> ` PKG. TREATMENT PLT.`❑ ! Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED ❑ Distance to nearest: Well _ <br /> Foundation p y <br /> c �. • Number <br /> Size <br /> SEEPAGE PITS *"y I l Depth Foundation Property Line <br /> I SUMPS ❑ Distance to nearest: Well f t <br /> f 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, an <br /> rules and regulations of the San Joaquin Local Health following: <br /> lio ing <br /> Home owner or licensed agent's signaturecertifies the <br /> subject Ito wrorkman'srtcompensation lawsofCaliforrnia." Contractor's_ _ lhir hiring or sub-contractings permit is lsignatuore <br /> employ any person in such manner arsons subject to workman's compensa <br /> certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ p <br /> tion laws of Califon <br /> Ilcan mu call for ail required ins ti ns. Co plate ing on reverse side. <br /> The app t Date: —L-�� <br /> Title: <br /> Signed X - - _ _ r .w <br /> WIDE <br /> ' PARTME T USE ONLY ©'"` <br /> Z� Area 1 I <br /> Rate p <br /> l ti Application Accepted by <br /> f pate n � ;17 Fin I Inspection b Dated <br /> `Pit or Grout Inspection by <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 5-63B5 <br /> Applicant - Return all copies to: Enviropmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 <br /> � Lx !)ecr��. <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> r.EH 13-241REV.I/H5) f 3 D <br /> £H t4-29 <br />