Laserfiche WebLink
j� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -:: _(Complete,(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. j <br /> Job Address <br /> 3 FOR 5 City / .)/ IX -Lot Size PM t <br /> _ /r <br /> Owner's Name D "r <br /> 14 GX Address 5 A4 /Y7 C Phone <br /> ' Contractor's Name <br /> , License No. Phone <br /> g9/ - <br /> rw� TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ ,.._DESTRUCT.ION=❑ ; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER El } {: <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE p <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CAS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom F-1MantecaDia. of Well Excavation I 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- Z140 <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 Stop 501 <br /> Depth __Filler.MaterialABelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION N DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I Commercial Other <br /> Number of living units: /I. Number of bedrooms <br /> Character of soil io a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> kk Method of Disposal <br /> PKG. TREATMENT PLT. ❑ f k <br /> Distance to nearest: 'Well Foundation I Property Line <br /> } i <br /> LEACHING LINE1 ❑ No. & Length of lines ) Total length/size <br /> FILTER BED Distance to nearest: Well ����"� Foundation 5'0 Property Line <br /> SEEPAGE PITS , ' ❑ Depth --Size Number f <br /> SUMPS LlDistance to nearest: Well; Foundation E Property Line e <br /> DISPOSAL PONDS ❑ 1 l <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 District.---- --------- i t j - <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 II for all required inspections. Complete drawing on reverse side. <br /> P <br /> Date: /,/- <br /> Signed - - Title: A <br /> FOR DEPARTMENT USE ONLY <br /> { ` -7 Area <br /> Application Accepted by +"'� """" Date <br /> Pit or Grout Inspection`liy � � '°' V Date Y. Final Inspection by Date <br /> t _�^ / <br /> Additional Comments: <br /> C-1Stk466-6781 € ❑ Lodi 369-3621 E Manteca 623-7104 ❑ Tracy 835-63%i <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 REI1AlTTED! �CK' rRECEIVED BYDATEr PERMIT'N0 - y-. <br /> f INFO CASH <br /> + EH 13 <br /> -24{REV.101831 ®v <br /> EH 14.26 <br />