Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED r <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 /> C 649 for sewage or No.,1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin ouniy Ordinance Na. <br /> Local Health District. <br /> } ! /`eM v st City -S Lot Size dCrf PM <br /> l dob Address <br /> Owner's Name f <br /> n Address d-Its° Phone <br /> C <br /> Phone <br /> Contractor's Name <br /> License No. <br /> i TYPE OF WELL/PUMP: I� NEW WELL WELL REPLACEMENT C] DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR E! OTHER El <br /> 44 14 f SEWER LINES., DISPOSAL FLD. PROP. LINE ._ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2104 �- <br /> FOUNDATION AGRICULTURE WELL IVAd/ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 4 ❑ Open Bottom LD <br /> Dia. of Well Excavation_ j� Dia. of Well Casing <br /> ❑ Industrial ;l Specifications `tit? <br /> I. <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> El Other r fl Deka Depth of Grout Seal ` Type of Grout ICA fP � <br /> ❑ Public III`` -" <br /> X Irrigation �pprox' Depth ,Eastern Surface Seal Instalked by <br /> Ii. H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump -- F I - ( , <br /> Well Destruction Ll Well Diameter 3 Sealing Material itow p 50') <br /> Depth Filler Material [Belo50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Elalvailabpeiwith ne200 feetitted if public sewer is <br /> i <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: L Number of bedrooms <br /> ; Water table depth <br /> Character of soil to a depthof 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> F; Method of Disposal <br /> PKG. TREATMENT PLT. ❑ . - <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ : Na. & Length of lines Total length/size— <br /> FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line <br /> ie <br /> Numb <br /> I SEEPAGE PITS ❑ Depth ` ' Size' Number <br /> SUMPS Ll Distance to nearest: L Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ , <br /> I hereby certify that I have pirepared 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_anyeperson•in-such ramie,nner as tohecomesubject to worlunan,s compensationJaws of.California..=Contractor's=hidog or,sub-con!ractiiz—s aLN - <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 a aired inspect ns. Complete drawing on reverse side . <br /> Signed Title: - <br /> ! FOR DEPARTMENT USE ONLY J X1 <br /> ;!!!� , Date +�-IArea <br /> Application Accepted b 1' <br /> 477 <br /> 3 <br /> Pit or Grout Inspection y -Date2--Zj Final Inspection by Date <br /> Additional Comments: JI <br /> p Stk 466-6781 El Lodi 369-3621 C1 Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED C RECEI4'ED BY DATE PERMIT"NO. <br /> INFO 11 <br /> + EH 13-24 IREV.101541 <br /> _. ; <br /> *..EH 14-26 - - , <br />