Laserfiche WebLink
APPLICATION <br /> FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> i Telephone {209) 466 6781 <br /> PERMIT EXPIRES TYEAR 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 /> a� City��3� Lot Size °sR aif_ 4_. PM <br /> I Joh Address j cul� <br /> Owner's Name' + cul 1 p- Address 3 _�Qi' ePhone <br /> tf 1`p �U� c� ! License No. �. Phone <br /> ContractorVallen Address �� <br /> TYPE OF WELL/PUMP: NEW WELLK WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 1490 PROP.E�� <br /> _ r <br /> _ FOUNDATION- 'AGRICULTURE WELL } OTHER WELL ��_ .-,PITS/SUMPS f=�D f <br /> G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r. <br /> 12 Industrial )9.Open Bottom LI Manteca <br /> Dia. of Well Excavation / Dia. f Well Casing <br /> i�K Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing e- `Specifications <br /> f l Public r 17-1 Other f 1 Delta Depth of Grout Seal r _ rt Typg of Grout� .I1rs.G►+� <br /> V` <br /> I I Irrigation Approx. I,l Eastern Surface Seal Installed by f`. I _ <br /> Repair Work Done D Type of Pump . 3 H.P. State Work Done_ rR <br /> ...»..-..,.... .. � 111 <br /> Well Destruction ❑ Well�Diameter�_ -�. r Sealing Material ltop 501 f <br /> Depth Filler Material {Below 50') - <br /> ti TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIRLA•DDITION i I DESTRUCTION { I (No septic system permitted if public sewer is <br /> - �T4 available within 200 feet. <br /> Installation will serve: Residence Commercial_""'Othe-, ---�4 <br /> a Number of living units: Number of bedrooms ' t.- t t <br /> Character of sail to a depth of (,C "`- Water table depth <br /> SEPTIC TANK ❑ .Type/Mfg. Capacity —.,-No. Compartments <br /> f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line # <br /> ° LEACHING LINE ❑ No. & Length of lines,�""f Total length/size * ' <br /> . FILTER BED ❑ Distance to nearest: kl_y"Il — Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: ' Weil Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> 1 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 Diltrict. <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-.asAo-become subject to workman's compensation.laws of..California.'M.Contractor s-hiring-or s6b-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 /> i x <br /> The applicant m st call for all req rad inspections. Complete drawing on reverse side. <br /> k <br /> • Signed Title: � P f /Z _ Date: <br /> r <br /> k FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area06), <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: -- <br /> ❑ Stk 466-6781 _ ❑ Lodi 369-3621 _ 0 Manteca, a23-7104,,, 'O Tracy. 835-W5,­. <br /> Applicant - Return a!I copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII'NO. <br /> r +.EH 13-24.,(REV.+i x 5) <br /> EH 14-26 <br /> -P <br />