Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 2 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. !83 7 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sin Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and�gJ Regulations <br /> oof the San Joaquin Local Health District. <br /> Job Address 1 Q Y%r\ Subdivision Name `— <br /> Owner's Name 0N' V&S Address p3 L. IPM lornl_ Phone <br /> Contractor's Name p/ License,No. Phone <br /> 1 _ ! <br /> TYPE OF WELL/PUMP WORK: NEWIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ W <br /> PUMP INSTALLATION ❑ ---""SYSTEM-REPAIR' —L " OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION j AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> k Other Delta y <br /> k <br /> 17 Public ❑ � EJ ` Type of Casing <br /> Lj IrrigationApprox ElEastern* Specifications <br /> ❑ Cathodic Protection f Depth of,Grout Seal <br /> Geophysical Type of Grout' <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done Lr Type of Pump H.P. State Work Done <br /> Well Destruction L Well Diameter Sealing_Material (top 501) _ <br /> Depth _ Filler Material (Below 50') <br /> kTYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> i Other available within 200 feet.) <br /> installation will serve: Residence Commercial <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg: Capacity No. Compartments <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Y <br />€ SEWAGE SYSTEML istanci o res Jell F dation . Property Line <br /> DESTRUCTION . a A <br /> LEACHING LINE U No. & L;ngth of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation] Property Line <br /> I ' <br /> SEEPAGE PITS Depth 'Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L <br /> I hereby certify that I have prep1red this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules, <br /> jand 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanIs compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California," <br />! The applicant mu �llfall qu ea i pe ions. Complete drawing on reverse side. <br /> X <br /> Sign <br /> Title: Date: <br /> D RTMEN --ONLY Stk 466-6781 <br /> Application Accepte Area <br /> Additional Commen + " ❑ Lodi 369-3621 <br /> Pit or GroutInsp ct' Date L Manteca 823-7104 <br /> i <br /> Date �� ❑ Tracy 835-6385 ; <br /> Final Inspecton <br /> 0D9, 5t k., CA 45201 <br /> Applicant - Return all es o;' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2 <br /> DATE PERMIT N0. <br /> FEE BASE AMOUNT DUE ]}AMOUNT REMITTED RECEIVED BY <br /> INFO <br /> 10182 500 <br /> EH 13-24 REV, 10182 <br /> 14-26 <br />