Laserfiche WebLink
R APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> ',1 Y 1601 E. HAZE T ON AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. 1 <br /> r3,",STI :n (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. - ` <br /> Job Address <br /> .� � -eil1 .�-,r City Lot Size i� Pm <br /> w J► r-rr i)g] k 33 3 P.V►+$ Pho`e -Owner's Nam � T Address <br /> - -4 <br /> — �r <br /> 4 License No. Phone Contractor Address - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ i <br /> S- �.. t} DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES_ <br /> FOUNDATION- AGRICULTURE WELL";_— � OTHER WELL PITS/SUMPS <br /> INTENDED-USE TYPE`OF WELL.,.,,.,,PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca ' D�'ofiWeli.ExcavationDia. of Well Casing -' <br /> EJ Do 1❑ Gravel Pack '�Q Tracy Type of Casing _ �4;cifications �t <br /> �• "t ~ <br />€ ❑ Public ❑ Other Z3-Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ` _-4pprox..Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump State_ Work Done ` '"' <br /> ids <br /> Well Destruction LI Well Diameter Sealing Material (top 50'1 <br /> IDepth ' Filler Material,I Below 501 <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION ❑ [No septic system permitted if public sev"uer is ?+° " <br /> available within 200 feet.) <br /> Installation will serve: _Residence-)Z- Commercial_ Others ", <br /> Number of living units:° Number of bedrooms <br /> # 10 <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC YANK., ❑ Type/Mfg Gapacity� No. Compartments <br /> y. <br /> z PKG. TREATMENT PLT. ❑ tj�� Method of Disposal <br /> .,..,. � .� ,.. _ c, i <br /> aW <br /> Distance to nearest: Well .. Foundation 40 Property Line; <br /> ,. t <br /> yN Z ere Total length/size © f <br /> it <br /> LEACHING LINE E] No. & Length of lines <br /> FILTER BED Distance to nearest Well ? Roundation ` } Property Line <br /> SEEPAGE PITS 11 Depth _Size Number <br /> ge <br /> SUMPSi❑ Distance to nearest: T• Well LO[y r.Foundation arZ�l Property Line <br /> I DISPOSAL PONDS ❑ <br /> 1 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: -'I certify 1hatin the performance of the work for vzrvhich 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 following: "1 certify that in the performance of the work which this permit is issued,I shall employ persons subject to workman's compense- <br /> tion laws of California." R <br /> The applicant m call for all require ins pe tions. Complete drawing on reverse` ide. . <br /> 1§1gned '. ` <br /> 'title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> a <br /> Application Accepted <br /> Grout Inspectio Date l�1" � �V;I�Z�/Date ea <br /> Date inal Inspection by <br /> f. it � � � <br /> I � <br /> $._ Additional Comments: i <br /> f ❑ Stk 466-6761 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copi„ to:.,Environmental.Health-Permit/Services 1601E. Hazelton Ave., P.O. Box 2009, Stk CA 95201 <br /> r <br /> k FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH13-24Sr{evt/a51 Q0 � <br /> �` EM 14.28 <br />