Laserfiche WebLink
IN APPLICATION OR:PERMIT <br /> t:J <br /> SAN aOAQVIN LOCAL HEAIwTH DISTRICT {� <br /> •r l E S -� t•` r ���V'1 <br /> 1601 E. Hx"z ON 1A1/E., STOCKTON, CA L✓ <br /> Telephone (2097 4666-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> l (Complete in Triplicate) e <br /> s This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heejt <br /> d. <br /> made in compliance with San Joz uin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules an Re tions of the San Joaquin <br /> Local Health District. I <br /> i p City_FV—lemJ& e PM <br /> Job Address <br /> 4 Address hone ~SS <br /> Owner's Name 1 <br /> Contractor <br /> A Address + �- License No. Z � � Phone <br /> TYPE Ot WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ `' SYSTEM REPAIR,❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE {,� <br /> DISTANCE TO NEAREST: SEPI IC TANK } v� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C1� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca) Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' ! Type 9 Specifications <br /> T e of Casin <br /> �I ❑ Delta's Depth of Grout Sea! Type of Grout <br /> FI Public n OlIther �� � � f.,r i� 1 4� I � _ <br /> ��4�Approx. Depth I 1 fasfern l # 'S" ace`Seal Installed by <br /> I I Irrigation <br /> `_ � ` State Work Done <br /> Repair Work Dane IIi� Type of Pump ". H=P. I f <br /> Well Destruction ❑ Well!Diameter ,,}Sealing liAa enol atop 50'1 i <br /> Depth :Filler Materi�l IBelaw 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 7 R aAIFt/ADDITIONNIr DESTRUCTION I !�avlailabpelc system within 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial other <br /> Number of living units: 9 Number of bedrooms;-1_._ <br /> Water table depth <br /> Character of soil to a depth.�of 3 feet: <br /> r � <br /> SEPTIC TANK ❑ Type/Mfg € Capacity No. Compartments <br /> , <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property.Line <br /> i --1 J Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ V'Ipistance to nearest: WfII I Foundation <br /> Property Line <br /> Size Number <br /> SEEPAGE PITS t ] Depth <br /> "`SUMPS Ll Distance to nearest: Well Foundation Property Line iw <br /> DISPOSAL PONDS ❑ '. -Y-- <br /> I here�y cercif �hhave prep ted this bpplicatroh and that the work will be done in accordance with San Joaquin county ordinance`s, state laws, an <br /> rules an gulatiods o he fah J`oaq�i in Local Health_bist_rid, <br /> Hom caner or licensed Brit's signature certifies the followlri "I certify that in the performance of the work for which this permit is issued, l shah not <br /> i em oy any person in suc manner, s o beco bject+to warkman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> ce ifies the.followi g: "! ertify that 1 he pe r nce o the work for which this permit is issued,!shah employ persons subject to workman's compensa <br /> ti n laws of Califo nia ' ; <br /> applicant I or a� rem { s: C., plele i rawing on v r sid ��yy / �� <br /> T e app t ofd e-V <br /> Signed <br /> yt r w � - <br /> I Title: Date: <br /> 4;1x1_i <br /> FORDEPARTMENT USE ONLY <br /> I � f <br /> Date Area <br /> t Application Accepted by i�.V fry <br /> € ill Date Final Inspection by Date Z _- <br /> Pit or Grout Inspection by I� <br /> r Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantecar b23-7104 ❑ 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 /> dIT�NO. <br /> ffFEEFAM10rUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM <br /> +.EH 43.21 IflEV.aµ51 <br /> EH 14-H <br />