Laserfiche WebLink
0 ` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-67$1 <br /> U PERMIT EXPIRES 1 YEAR'FR'OM DATE ISSUED - <br /> (Complefe 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. 1'862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. c` _ <br /> Job Address -, ef-b City 'Lot Size PM <br /> Owner's Name (r'OR);5- T- Address- J 966A:5041 PhoneS38- 41,19&0 <br /> Contractor " [" Address?140 ;i3 C r1-7t /��icense IV0.114 E�le Phone. �E 7 7 \1 ! { <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 /> I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f I <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Specifications r I <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout L <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump " H.P. I State Work Done IUZ517 11DI29:25;. T a <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> J ! <br /> Depth Filler Material (Below 501 � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is,I r <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other �f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth a <br /> SEPTIC TANK ❑ Type/Mfg Capacity; No. Compartments <br /> PKG. TREATMENT PLT: ❑ Method of Disposal 1. <br /> Distance to nearest: Well Foundation Property Line { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> t f <br /> SEEPAGE PITS ❑ Depth Size Number # <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line 4 <br /> DISPOSAL PONDS ❑ <br /> —�-Imereby certify that I have prepared this application and that the work will be done in accordance with San"Joaquin-county b0dinancbC,-state laws, and t <br /> rules and regulations of the San Joaquin Local Health District. ( f <br /> Home owner or licensed a ent's signature certifies the following: - <br /> g 9 g: "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." Contractors hiring or sub-contracting signature <br /> certifies the fol g:"I certify that in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> The laws a us 1 -410 <br /> The app cant mus c I f all ed I s. Compl to drawing o erre si e. <br /> i .. <br /> Signed Title: I.-" Date: I <br /> FOR DEPARTMENT USE ONLY <br /> _ a � <br /> Application Accepted by Date `�— Area �� a <br /> s-�= r <br /> Pit or Grout Inspection b Date Final Inspection b Date <br /> I I <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑'Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Per 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r I <br /> }NFO AMOUNT DUE AMOUNT REMITTED-- "" K p�CEIVED BY`� ?—'6ATE k k MIT•'N0.• �� ��� <br /> . + EH CASR <br /> 196- <br /> EH <br /> ... �- T� �'� _ !/�1. •� ,��#�' �. �.� - <br /> EH 1426 1 x <br />