Laserfiche WebLink
_ N <br /> r <br /> APPLICATION FOR PERMIT <br /> w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> e r <br /> Job Address 2q.2-2 City S Lot Size 2-M PM <br /> Owner's Name,"in Address / u r O Phone K,9 <br /> Contractor's Name/?—e— Wal S n s e No. I ,3 9Phone O —J-9 2 Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 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 i <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 n j <br /> Depth Filler Material (Below 501 f�1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other _ J <br /> Number of living units: Number of bedrooms 2 <br /> Character of soil to a depth of 3 feet: Water table depth �q <br /> ! F <br /> SEPTIC TANK El /;?-0 0 <br /> Type/Mfg � Capacity No. Compartments � <br /> PKG. TREATMENT PLT. ❑ �/ Method of�Disposal <br /> Distance to nearest: Well�I Foundation��l Property Line �c! 'f <br /> LEACHING LINE ❑ No. & Length of lines 'a- A)0 f Total length/size 1 U <br /> FILTER BED ❑ Distance to nearest: Well N 0 V%A!t Foundation /d T ' . Property Line J <br /> SEEPAGE PITS ❑ Depth — Size 3 —7 Number <br /> SUMPS ❑ Distance to nearest: Well ti JNZ Foundation A) 1470" Property Line Z <br /> DISPOSAL PONDS ❑ <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 /> 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed 771 Title: �A Date: <br /> ( FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date CCCCCC»���1KKKKKJ11111 Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: +� <br /> Stk 466-6791 ElLodi 369-3621 11 Manteca 823-7144 ❑ Tracy 835-6385 <br /> App Pcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH 13-241REV.10!831 Ica ' �� <br /> EH 14-26 <br />