Laserfiche WebLink
T<- - <br /> 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 1 YEAR FROM DATE ISSUED <br /> j (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. , ,i; <br /> { J f �f <br /> Job Xddress v€ VF IES_2 Ci ize f !low M <br /> Owner's Name'L- Address Phone <br /> ,....s. �Contractor-ice. UCLIg1.1._T.-f)E�I�L Address_-. 'J�.d' _ _ ' _ License_No._. .lar —Phone .. 6. <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 <br /> -'"""""`""'�'Cl-Industriat------ -*'-E-Open-Bottom 171-Manteca -^ Dia--of-Well-Excavation----­­------- Dia.of Well-Casing­-- <br /> "D <br /> Casing­--'❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation +__Li'�Approx. Depth ❑ Eastern Surface Seal installed by <br /> t7­7 TM 'Repair Work Done ❑ `Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sg0ing.Material (top 501 <br /> Depth Filler Material (Below 501 <br /> :TYPE t7F.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Iristallation udill senie''ERes <br /> uen:e=j . <br /> Commercial==-ether^- " '� <br /> Number of living units: Number of bedrooms f ! l <br /> Character of soil to a depth,of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �.�y C�tJ 1 E Capacity t �O # No. Compartments <br /> i PKG. TREATMENT PLT. ❑ M 1f Method of Disposal <br /> I' Distance tot nearest: Well 1f� Foundation }Property Line r o } <br /> LEACHING LINE No. & Length of lines ;)LL— - Total length/size <br /> FILTER BED e 13Distance to,nearest: Well Foundation Property Line— <br /> SEEPAGE PITS~ /Depth - Size y Number <br />� � f � - <br /> SUMPS 11-..Distance to-nearest: Well FoFuntdation-­Property Line <br /> DISPOSAL;PONDS ❑ 'y <br /> 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-Distrid. <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 /> 71_ rtifies the following:" ertify that in the performance of the work for which this permit is issued,!shall employ persons subject to workman's compensa <br /> tion of California.' <br /> The applica u call for al equir ins ions. o towing an r verse sid <br /> Sig tle: r Date: <br /> FOR DEPARTMENT USE ONLY <br /> I I <br /> Application Accepted by Date ` Area <br />` Pit or Grout Inspection by Date Final Inspection by Date <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ZPERMIT'NO. <br /> INFO,EH 13-24 IR EV.i/o 51 •^` �y -1(off <br /> EH 14-28 1 <br />