Laserfiche WebLink
. <br /> Sr <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN9LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209,)1466-6781 , <br /> PERMIT EXPIRES 1 YEAR PROM 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 `S <br /> made in compliance with San.Joequin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> w A <br /> Local Health District—, <br /> Job Address {� City Lot Size C 5-L S PM <br /> Owner's Name +� f !j Address T Phone <br /> Contractor's Name License No. f Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO ❑: SYSTEM REPAIR ❑ Jr OTHER ❑ <br /> IS To TO NEAREST:.SEPTIC TANK I�f - SEWER LINES­k_ i DISPOSAL FLD : � w-PROP. LINE <br /> 1 FOUNDATION 21 s AGRICULTURE WELLS—.► OTHER WELL>r` -•rPIT,S/SUMPS <br /> INTENDED USE TYPE OF " ELL PROS ARES CONSTHMTr0�V"�PM5 CAT1_6VS_ <br /> ElInduRn 1 1 Open Bottom ❑'MaSlteca Divbf Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing — Specifications O y` <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t, Type of Grout P J <br /> ElIrrigation �pprox. Depth El Eastern <br /> Surface-Seal Installed by <br /> Repair Work Done ❑ ' Type of Pump H.P. I �State.Work Done' <br /> Well Destruction ❑ Well Diameter Sealing�Material (top 50'1 <br /> Depth Filler Material (Below 50'), <br /> f. V <br /> TYPE OF iSEPTIC WORK: NEW INSTALLATION 171REPAIR/ADDITION ❑ DESTRUCT(ON•I],INo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Insta lation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms , <br /> Charact r of soil to a depth of 3 feet: y ' Wate table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. 6ompartments <br /> PKG. TR TIVIENT PLT. ❑ ; ` Method of Disposal <br /> Distance to nearest:` Well Foundation Property Line <br /> Total len h/size <br /> LEACHING?L ❑ No. & Length of lines <br /> I FILTER BED1 ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE{PITS Cl 'h Size Number . <br /> SUMPS / ❑ Distance to nearest: Well Foundation Property Line <br /> ); DISPOSAL',FONDS ❑ <br /> 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.—T, <br /> Home owner or licensed agent's signature certifies the following: '9 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 bebbrhe subyec�t to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work fdr whieh_this permit is issued I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> k F,�„�4,.�- { sir E <br /> The applicant u call 8i1 ' inspections plate drawing an re5e side. <br /> Title: ��~ — Date: <br /> Signed ti = it <br /> FOR DEPARTMENT USE ONLY <br /> QDat Area , <br /> Applicati f Accepted by e <br /> ,� .: . Date <br /> Pit or rout Inspection by f` Daf� Final Inspection by <br /> fes`. <br /> C. + '6 x y <br /> Additionaf Comments: <br /> y"❑ Stk 466-6781 O-1i '-369-3621 C] Manteca Ii23-7104 ❑ Tracy 835-6385 € <br /> k Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> L <br /> # f1ECEIVED BY DATE PERMIT'NO.- , <br /> 1 INFO <br /> +EH 13-24(R <br /> EH 14-28 ©` e, i. <br /> t 1 r I <br />