Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaqujn 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 29 f f d <br /> Cit r� <br /> Y Lot Size v QPM <br /> Owner's Name J Address �f7t Phone <br /> RR. <br /> ConlractoC12� G � � Address ? s f <br /> try License No. v �n <br /> TYPE OF WELL/PUMPhonew <br /> P: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> C1 SYSTEM <br /> ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private 1-3GravelPack " Dia. of Weil Casing <br /> ❑Tracy Type of Casing <br /> C1 Public Specifications <br /> Cl Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation _ Type of Grout <br /> --Approx. Depth f I Eastern Surface'Sea! Installed by <br /> Repair Work Done ❑ Type of Pump H.P, <br /> State Work Done <br /> Well Destruction ❑ Well Diameter , <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 91 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial available within 200 feet.) <br /> ` Other <br /> Number of living units: Number of oom l <br /> Character of soil to a depth of 3 feet: -4 �� <br /> SEPTIC TANK Water table depth <br /> IrType/Mfg ! f? . E.2 CapacitNo. Compartments < <br /> PKG. TREATMENT PLT. ❑ r <br /> /�� / Method of f]isp�sal <br /> Distance to nearest: Well Foundation_ d <br /> Property Line CQ�,— „ <br /> f <br /> LEACHING LINE 144-�No. & Length of lines <br /> FILTER BED f Total length/size <br /> ❑ Distance to nearest: Wel! ` r <br /> Foundation�Q Property Line�__ <br /> SEEPAGE PITS Y'1�Depth Size C, <br /> L� Distance Number <br /> stance to nearest: Well�[`_ Foundation0 <br /> DISPOSAL PONDS F-1 Property Property Line—2,T-- <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 Jaws,. -- <br /> rules and regulations of the San Joaquin Local Health Dviltrict. <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 applicant st call fo►-1-51eZqjfed inspections. Complete drawing on reverse side. <br /> Signed X J �! Title: !J <br /> Date: V� <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by <br /> 09 <br /> Date Area <br /> or Grout Inspection by ►' <br /> Date -� Final Inspection byGer D � 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104I <br /> 5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazet on Tracy A3ve., P.O. Boz 2009, Stk., CA 95201 { <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO C SH RECEIVED BY DATE PERMIT*NO, <br /> r.EH 13-24INEV,rlA 51ITO.Q <br />