Laserfiche WebLink
it <br /> APPLICATION FOR PERMIT <br /> � <br /> 7, <br /> r <br /> Ii SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t i 1601 E. HAZELTON AVE., STOCKTON, CA <br /> II <br /> Telephone (209) 466-6781 <br /> II PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �C7� <br /> (Complete in Triplicate) <br /> I 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 /> I 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 /> , <br /> Job Address Ero R OLW/a y �dC�C�"'� Lot Size <br /> Cir PM <br /> E � <br /> ydwner's Name ca_� e-I `T J1A G" i A-ddress Phone S/ GYy 7 <br /> ontfactor �I Address ' <br /> License No. Phone <br /> TYPE OF WELL/PUMP:. 7 <br /> � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> j <br /> F1 Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f`i Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout_—_ <br /> I I Irrigation _IYApprox. Depth I I Eastern Surface Seal Installed by <br />} <br /> Repair Work Done ❑ Typerof Pump <br /> H.P. State Work Done _ <br /> Well Destruction 17 Well 'Diameter Sealing Material (top 501 <br /> i <br /> Depth Filler Material (Below 50') \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] " REPAIR/ADDITION i I DESTRUCTION No septic system`permitted it public sewer is �3 <br /> 0 a ailable within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundationr <br /> Property Line <br /> li <br /> LEACHING LINE ❑ No'. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt -Foundation Property Line <br /> Id <br /> SEEPAGE PITS I I Depth Size <br /> Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. r <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall of <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signat <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." II <br /> �( The applicant must c Ifo all required inspections. Complete drawing on reverse side. <br /> Signed X �/�/f <br /> T+fle: �t 9 Lv+v e X <br /> Date: <br />" F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Date I <br /> I - 9 s <br /> Pit or Grout Inspection by Final Inspection by <br /> Date <br />' Additional Comments: <br /> c. <br /> ❑ Stk 466-6781 ❑ odi 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE A OUNT DUE AMOUNT REMITTED CK <br /> IN 1. CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦.EH14-24(REV.t i x 5) <br /> EH 1426 <br />