Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> 1601 E. HAZEL TON"AVE.,"STOCKTON, CA <br /> . Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1'YEAR-FROM DATE 'ISSUED,' ' <br /> (Complete in Triplicate) ` ­4-'i?. �V wiii` -° <br /> t 0.j1SDvl I r <br /> Application is hereby made to the San Joaquin#Lo al Health District for a permit to construct and/or stall 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 /> Local Health District. ,u=- <br /> 2477©.<�� .1.:6+ r,,,�..•AA� r f,_,� �t ' r' 797— 37 <br /> Job Address Cit;` Lot Size L�+G�[�`/� P.M '. <br /> Owner's Name + VA 1iAddress <br /> 96-hone , <br /> Contractor Address "C . W1`! License No. Phone 6" <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION FIPUMP INSTALLATION 1-2LL <br /> REPAIR ❑ OTHER ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 5 DISPOSAL FLD. PROP. LINE <br /> i\ i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial If 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 w Depth of Grout Seal <br /> l <br /> El Irrigation Depth ❑ <br /> Irrigation _ J j <br /> Eastern � "Surface Seal Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump H.P.'4L �, , State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top'501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is } <br /> I :. available within 200 feet.) <br /> Installation will serve: Res}'deuce Commercial_ Other <br /> Number of living units: r Number of bedrooms �— <br /> y —>e <br /> Character of soil to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK s ❑ ' Type/MfgV �C1C/ M <br /> Capacity_ . ONo. Compartments <br /> PKG. TREATMENT PLT. ❑ ,� T Method of Disposal <br /> .Distance to nearest:,r. Well J_c�. Foundation ILQ _ Property Line <br /> LEACHING LINE ❑ No. & Length of'lines ` Total length/size 1%LJ <br /> FILTER BED — Foundation Property Line <br /> ❑ Distance to nearest: Well <br /> SEEPAGE PITS <br /> . I( Depth Size Number t <br /> SUMPS ❑ Distance to nearest: Well 5A�%O-_ Foundations Property ' <br /> DISPOSAL PONDS 11r p y Line <br /> 1 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. <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 /> ect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subj <br /> certifies the following:"I cern at 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 rnia." <br /> r � i <br /> The appl' ant mus c fo requ' d spections. Complete drawing on r rse side. <br /> Signed <br /> Title: �(- <br /> Date• <br /> FOR EPARTMENT USE LY <br /> Applicati Accepted by alt 4A Date L�J5 Area _ <br /> (:9)rGrout Inspection by Date�S Final Inspection by �M ate " S <br /> 4 <br /> Additional Comments: - <br /> 11 Stk 466.6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aye., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 124 IREV.S/a 5S <br /> EH,44-2a <br />