Laserfiche WebLink
^ '\ APPLICATION fOR PERMIT <br /> /•� ,V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v 1601 E. HAZELTON AVE., STOCKTON, CA . <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEt? <br /> (Complete in Triplicate) <br /> Application is hereby made to the San.Joaquin Local Health District for a permit to construct andlor install the work bdwThl ap¢ticinion 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 /> U' <br /> Job Address ftr, � jS� Cityllz +VAO;`ot,size 'too f. 1.<`CI ;PM <br /> -Owner's Name Address /9(/3:SX4a 6AnD Phone <br /> Contractor4%4J(.Add;essJZX%­,— License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPLACEMENT ❑ 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 <br /> ❑ Industrial ❑Open Bottom ❑Manteca Qia ofWeEx'ayatiQnDia.of Well Casing, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Typ"f.Casing Specifications <br /> F"1 Public ❑ Other F1 Deltaf"' (74)epth(5i#angor Seal Type of-&wt <br /> f <br /> I )Irrigation —.Approx. Depth I I Eastern ':Se'Jace Seal Installed by <br /> Repair Work Done 11Type of"Pump H'P. State Work.Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itopr 50') <br /> Depth Ffflw Material Y Below,501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCT) I (No septic system owr tted"if,pum seweris {,� <br /> availebl*within 2DO,feet.) <br /> Installation will serve: Residence_ Commercial— Other. " <br /> Number of kving units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water tabledepth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> {Method of Disposal <br /> PKG. TREATMENT PLT.❑ - <br /> ,..; <br /> Distance to nearest: Well Foundation Property bne s , <br /> ,s <br /> LEACHING LINE ❑ No. $Length.of Tines Total Iength/s/s <br /> ize <br /> FILTER BED ❑ Distance to nearest: Well foundation_ _ Property`Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS ❑ Distance to nearest. Well Foundation Prowty Lim 'J <br /> DISPOSAL PONDS O <br /> I hereby certify that i have prepared this application and that the wort Vt!!!1 41me in accordance wlt#►'Sen JaawhiWAURW ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health Qibtrict. <br /> Home owner or licensed agent`s signature certifies the following:"I ceitif�I that in the perfpmpance of the work for which this permit o issued, [,shall not <br /> employ any parson in such nl www as to become subject to wo;r'4 O nsa1 htlnis of�'t orrii ii.".Cohtractor's hiring or sub-contracting signature <br /> certifies the followir:-"I certify that in the performance of the work for which this permit is issued,i shall employ parsons subject to workmen's c ompens8 <br /> tion laws of California." <br /> The applicant call3eirDate: <br /> inspections. Ctfrnplete drawing on reverse side. <br /> igned Title: <br /> FOR 09PARTMENT USE ONLY <br /> Application Accepted by <br /> Date ICJ A0 Area <br /> Pit or Grout Inspection by Date Final Inspection by ` Date <br /> ' / - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑Tracy 8354085 <br /> Applicant• Return all copies to: Environmental Health Pernmt/Services 16Dt E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMrr-No. \' <br /> IN CASH �y�►/n� // ��, <br /> �.EH 13.241REV.I/Ra) � <br /> EH 14.2a <br />