Laserfiche WebLink
4 <br /> APPLICATION FOR PERMIT '=` E S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N D P—ti Lk <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '`*,,\S p�Y �, e '(lA��g , <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 sols N. ORO ST City 3-MA) Lot Size SO X 190 PM <br /> Owner's Name _&RQRy b G,/EQ Address 5e19 35' <br /> Contractor A> 6. I, 0d__P +Address_ 49.S A1. L.I"IAA!W AyE License No. q1C-7IL Phone C -39- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ I DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout n <br /> F-1Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _ H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 .t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:{Residence Commercial Other <br /> Number of living units: _/_ 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 /> PKG. TREATMENT PLT. ❑ F Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> FILTER BED ❑ Distance to nearest: Well fg Foundation Property Line__ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> 1 hereby certify that I have prepared this application and that the work wdl 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." <br /> The applicant must call for ail required inspections. 99motete drawing on reverse side. <br /> Signed X Title: Date: <br /> F D _ ENT USE ONLY 1 <br /> Application Accepted by v,7 Date 31-_1_ _ Area <br /> Pit or Grout Inspection byDate Y Final Inspection by �.C.0 Dat / <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO Qi AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. <br /> + EH 143-24IREV.4ies7 5J 'he <br /> �3� <br /> EH 14-28 <br />