Laserfiche WebLink
APPLICATION FORiPERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 <br /> ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <br /> J . This licatLon is <br /> to construct Application is hereby made o the <br /> Joaquin County Ordinance-No.iHealth District for a perm for sewage or No. 1862 for well/pump and the Ryles and ll the work (Regulations of he Sari Joaquin, <br /> made in compliance with Sanq _ , <br /> Local Health District. �•-- <br /> f ot Size PM <br /> f .r0 E9 T City <br /> Job Address <br /> ddress PA. 43 .2o,3 11 - Phone —Z <br /> Owner's Name 1 <br /> 1,, p 10 icense No.X216R-a-.-Phone <br /> Contractor Address / <br /> TYPE OF WELLIPUMP: NEW WELLS WELL REPLACEMENT DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13 , OTHER 0 ` <br /> I t ' DISPOSAL FLO. PROP. LINE _ <br /> DISTANCE TO NEAREST: SEPTIC TANK ��— SEWER LINES --���'�V� 1'—� ---4-- <br /> AGRICULTURE WELL-!:=— OTHER WELL PITSISUMPS ! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / N <br /> 4 _ Dia. of Well Casing (� <br /> ❑ industrial ❑ Open.Bottom Manteca Dia. of Well Excavation Specifications <br /> .,X Domestic/private Graval Pack, © Tracy Type of Casing <br /> ,T <br /> Public,: ElOther a ❑ Delta Depth of Grout Seai <br /> ype rout <br /> of G <br /> 0 irrigation —Approxi Depth ❑ Eastern Surface Seal Installed by <br /> 1 <br /> Repair Work Done ❑ Type of Purnp� H.P. State Work Done <br /> Well Destruction ❑ WellDiameter Sealing Material atop 501 ��• <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION © REPAIR/ADDITION ❑ DESTRUCTION ❑ (No <br /> wtine200 feet.) if public sewer is �J\ <br /> � 4 <br /> k Installation will serve: Residence Commercial_ Other <br /> a Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table.depth <br /> SEPTIC TANK ❑ Type/Mfgt <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 00 wd ��f y�Distancei 1 t nearest: Well Foundation Property Line <br /> 1. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 1 FILTER BED ❑ Distance. nearest: Well Foundation Property Line <br /> f SEEPAGE PITS ❑ Depth Size Number Q <br /> t <br /> property Line <br /> .Sumps .❑ Distance to nearest: -.Well ._ „ _}.Foundation_ A - <br /> DISPOSAL PONDS 0 <br /> I i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> f 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 /> i employ any personin 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 taws of Calffornia." ; <br /> The'applicant ust call for all req 'ed inspectio s. Complete drawing on reverse 41 a. <br /> tDate: <br /> Si g ned r. Title: <br /> h`9 I FOR DEP TMENT USE ONLY <br /> [ 4R a CT: <br /> f��� :7' �• ,,:_ Date Area <br /> Application Accepted'by "' <br /> r •° Date <br /> `+ y ate a7-#3 G Final Inspection by <br /> Pit r Grout`In ction by 7T <br /> Y' <br /> Additional-Comments:: <br /> I D Stk. 465-6781 �o ❑ L di:1369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <br /> Applicant;'Return all copies.toZEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IA <br /> .. ... FEE, <br /> - AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'Tt10. <br /> INFO <br /> LifZ FS X10—x-101 <br /> +EH 13-24(REV.t 10 til <br /> EH 14.26 <br />