Laserfiche WebLink
.T TM"-rr•`—'.°'��....�.r-s'`r _ . / / �Cif`"�— ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 /> 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. <br /> Local Health District. <br /> City <br /> at Size PM <br /> + Job Address <br /> Phan <br /> Owner's N Phone <br /> �Addres License No._ <br /> Gantratfar <br /> j 1VEW WELL ❑ ,,, WELL REPLACEMENT ❑ DESTRUCTION C1f TYPE OF WELL/PU t. SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _��� <br /> DISTANCE TO NEAREST:'SEPTIC TANK OTHER WELL PITS/SUMPS <br /> + FOUNDATION AGRICULTURE WELL _ <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUGTI(Sia4CIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavrart�n <br /> ""� <br /> Type of Casing' ' Specifications <br /> ❑ Domestic I Private EJ Gravel Pack Q Tracy Depth of Grout Seal �T_ k Type of Grout <br /> III <br /> 1-1PublicCl--Approx.Other 171 Delta <br /> -- - <br /> Depth I 1 Eastern _ Surface Seal Installed by / <br /> € I Irrigation H. _-State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> y` ^ <br /> Well Destruction F] Well Diameter -:Sealing Material (top 50'1 w1_ <br /> I Depth 'Filler Material (Below 501) <br /> y TYPE OF SEPTIC WORK: NEW IN jTALLATION I.1 REPAIRIADDITION I 1 DIE TR C I iti availablerw thin 200 feet.)ptc system if public sewer is ' <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms�— rk., <br /> Water table depth <br /> Character of soil to a depth of 3 feet: -, No. Compartments <br /> SEPTIC TANK ❑ Type IMfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 Property Line <br /> Distance to nearest: Weil Foundation <br /> f Total length/size <br /> LEACHING LINE ❑' No. &Length of lines Property Line <br /> FILTER BED -1 Distance to nearest: ; Well Foundation P Y <br /> I 1 Depth Size <br /> Number <br /> SEEPAGE PITS i Property Line <br /> SUMPS ❑ Distance to nearest: s Well Foundation P rtY <br /> € DISPOSAL PONDS ❑ <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 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 /> i 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 g1l , rail rewired inseections. Complete drawing on r side. 3 Q <br /> WA P'WeC Date: '�J �] <br /> Signed X <br /> R ENT USE ONLY <br /> m ct ^ Date Area <br /> I Application Accepted by <br /> Date Final Inspection by Data <br /> Pit or.Grout Inspection by i <br /> Additional Comments: r <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca (323-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> PERMIT <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK RECEI ED 9Y DATE 'NO. <br /> INFO <br /> + Err 13.24(REV.I/n 5) st �r <br /> EH 14-26 <br />