Laserfiche WebLink
APPLICATION FOR PERMIT 4-6,,, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA pi4y�yj�N , <br /> Telephone {2091 466-6781 RecelVEp <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� r <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or pstallr$jn descried• This f the SanIcation is <br /> J Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thtjle Ru R/Y11r +CQEALTH <br /> Local Health District. 1: FYI E'fVICES <br /> L City Lot Size PM <br /> ,lob Address <br /> Owner's Name <br /> AM ,C Phone <br /> Address <br /> License No. Phone _ 33" <br /> Contractor "t Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ RUCTION ❑ <br /> j PUMP INSTALLATION � SYSTEM REPAIR D OTHER ❑ ` <br /> i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: . EPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> 1p- <br /> -~Y INTENDED USE (TYPE OF WELL PRGfLEICif AREA CONSTRUCTION'SPEGIFlC4TiONS ala of Wel! Casing <br /> ❑ Industrial " Open Bottom ❑ Manteca Dia. of Well Excavation <br /> r Type of Casing Specifications <br /> )0 Domestic I Private ❑ Gravel Pack ❑ Tracy <br /> ❑ Public Type of Grout <br /> CI Other FI Delta Depth of Grout Seal <br /> � � _ <br /> I I Irrigation ! Approx., Depth l 1 Eastern S�JHa a Seal Installed by <br /> rz qT / f Z- State Work Done _ <br /> Repair Work Done ❑ TINpe of Pump . H.P. � �� <br /> ' t { Material {top 50') <br /> Well Destruction E �WeII Diameter Sealing <br /> Depth <br /> Filler Material iBelow 50'1 --�� <br /> i <br /> TYPE OF SEPTIC WORKr (NEW INSTALLATION I 1 REPAIR/ADDITION I ] DESTRUCTION l 1 INo septic system permitted if public sewer is s 1 <br /> available within 200 feet.) <br /> Installation willserve'✓isidence_� Commercial Other <br /> Number of living unite Number of bedrooms <br /> (t + Water table depth <br /> Character of soil to abdep h of 3 feet: <br /> SEPTIC TANK :1:E3 Type/M�g <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT f'LT.j�r l <br /> X11 Distancetoneatest: Well. Foundation Property Line <br /> LEACHING LINE ❑. No. 81 Length of lines Total Iengthlsize <br /> i Property Line <br /> FILTER BED ❑. Distance to nearest: Well Foundation <br /> SEEPAGE PITS 111 Depth I Size Number <br /> oper <br /> ' cnrrc4anon-�--- Prty-Line <br /> SUMPS d LI--Distancesia-nearest-.----W <br /> r <br /> -.-� DISPOSAL-PON13S J ❑ '. �r.., <br /> hereby certify tilat(have prepared this application and tha�,the work wifl�e done in accordance with San Joaquin county ordinances, state taws,-and <br /> .rules and regulations of the�San Joaquin{ocal-Health-Distriet, <br /> Horne g n <br /> e owner or licensed at's signature certifies the following: "I certify_ N that in the performance of the work for which this permit is issued, i shall not <br /> employ any person in such nner as to become subject to workman�,coinpensation laws of California." Contractor's hiring or sub cantraciing signature <br /> I ceffff�tttttif that in the performance of the work ford hjch this permit is issued, I shall employ persons subject to workman's compensa- <br /> cartifies the following: " y } pe <br /> tionlaws of Calif�rrnia." j,, l <br /> The applicant mu u' d ins - n pplete drawing!onl/reverse side. f� <br /> Date: II <br /> Signed X ; <br /> I FOR bElOARIMENT USE ONLY �f <br /> + <br /> gate p Area <br /> ! <br /> Application Acce ted by <br /> I bDate F Date OO <br /> Pit or Grout Inspection y al-inspection by } <br /> Additional Comments: <br /> k ❑ Stk 466-6781 ❑ -odi 369.3621 El Manteca 823 7104 ❑ Tracy 835 6385 <br /> Applicant - Aetum all copiais to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> I <br /> FEE CK REGEIVED BY ;DATE PERMIT'NO. <br /> INFOAMOUNT DUE AMOUNT REMITTED CASH " <br /> EH 14-26 <br />