Laserfiche WebLink
` a . <br /> �f 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 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 /> Local Health District. <br /> Job Address �Y 7 �0. t i �J City of Size- �` PM <br /> Owner's Name t?rpm. i4�7J/�' Address 5 Phone <br /> 111111 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR"El­-" OTHER Li <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE (� <br /> FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well"Excavation Dia- of Well Casing , n <br /> El Domestic/Private 11 Gravel Pack El Tracy Type of Casing Specifications V I <br /> ❑ Public ❑ Other '❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth i2-Eastern- Surface Seal installed by �} <br /> r <br /> Repair Work Done ❑ Type of Pump, H.P. State Work Done <br />� Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth I Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> "I-,/ available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> 1 Number of living units: I./ Number of bedrooms �^ <br /> Character of soil to a depth of 3 feet:' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg]� Capacity# No. Compartments <br /> t <br /> PKG. TREATMENT PLT. 11 � Method of Disposal <br /> Distance to,nearest:- Well--= Foundation-- Property Line_ <br /> IIr <br /> LEACHING LINE *1f1No. & Length of lines ��Y�C� Total length/size D <br /> FILTER BED ❑"- Distance to nearest: Well Foundation Property Line <br /> � t � <br /> I <br /> SEEPAGE PITS (!7 Depth t o`�jfr Size 3 %tJ Number f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I have prepared this Japplication 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. <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." `F <br /> The applicant must call for all required inspections. Complete drawing on reverse side. /4 <br /> Signed X /fit �26Ft�� Title: nweoQ Dater, <br /> OR T USE ONLY <br /> -may 3 <br /> Application Accepted i Date` Area r. <br /> I Pit or Grout Ins do yA ate Final Inspection by -,bate <br /> Additional Comments: oge-_42� <br /> ""0 Stk 466-6781 If Lodi 363621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20.09, Stk., CA 95201 <br /> " FEE AMOUNT DUE I' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> +EH 1324 IREV.10/631 <br /> I EH 142E , <br /> f v <br /> i <br />