Laserfiche WebLink
Mt APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �3 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ��Of-3 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (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 /> r Local Health District. e �f <br /> Job Address '777 <br /> 5 rocz-d LA—) City 7v/v Lot Size PM <br /> Owner's Name I e VJC .Address U��� � 77dL 1 �V <br /> Phone <br /> Contractor_" S� l-�' " Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I 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'tONSTRl1CTION-SPECIFICA'TI`O'NS <br /> i ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private L1 Gravel Pack ❑"Tracy Type of Casing Specifications — <br /> f'} Public f 1 Other I--] Delta 'De th of Grout Seal <br /> I � ,p Type of Grout - <br /> i I Irrigation 4-­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ .Type of Pump H.P. State Work Done <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material Ito p 50'} f <br /> Depth Filler Material (Below 501) Y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION 1 i . DESTRUCTION'X tNo septic system permitted if public sewer is <br /> "^a--�- Novailable within 200 feet.} <br /> Installation will serve: Residence— Commercial Other 2) ��G(� <br /> Number of living units: Number of bedrooms C <br /> Character of soil to a depth of 3 feet: Water table depth <br /> f SEPTIC TANK ❑ Type/Mf <br /> 9' Capacity No. Compartments V <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to'neal_rest: Well .� FY o nndatiod, Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well `"F6undation Property Line's }* <br /> SEEPAGE PITS t I Depth Size <br /> umber <br /> 1 <br /> SUMPS Ll Distance to nearest: Well Founda <br /> - 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, an <br /> rules and regulations of the San Joaquin Local Health District- <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 applic t ust call for t to it inspections. Comp to drawing on reverse side. <br /> K Signed X Title: w Date: <br /> FOR DEPARTMENT USE ONLY /%7 (_ ' <br /> Application Accepted by Date < �S <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection-by Date / <br /> Additional Comments. Z L <br /> ❑ Stk.466-6781 ❑ Lodi 3693621 1 'Cl Manteca 823-7104 ❑ Tracy 835-6385 �'M VO1tD-�,„�,�, <br /> Applicant- Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2011A, Stk., CA 95201 a[CS�D+-ld <br /> 4. <br /> vim <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT�_NO. <br /> INFO H v <br /> + EH 1 -24 IREV. /u sf lfrEN 1428 3 <br /> 00 c ! ll 01( <br /> ' <br />