Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> )PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) ;hl <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 /> Joh Address City Lot Size PM <br /> _ ' <br /> t / J <br /> Owner's Name, Gyri- ��-��• Address _ Phone <br /> �F-Y_3?6 ,".5":�r-/�s <br /> Contract o�, Address C �. t{ti, � License No. Phan <br /> TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION 1-1 <br /> PUMP INSTALLATION SYSTEM REPAIR 7-1OTHERD <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 /> Industria! ❑ Open Bottom (I Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public 171 Other ; D Delta Depth of Grout Seal Type of Grout---- <br /> I <br /> rout -I I Irrigation --Approx. Depth 1.1 Eastern �-{ Surface Seal installed by <br /> Repair Work Done Type of Pump H.P. CV v State Work Done I <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/AUDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Nurnber-of'living units:— - Number of bedrooms N <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. ❑ ~' Method of Disposal <br /> Distance to nearesti, Well Foundation Property Line <br /> k LEACHING LINE Ll No. & Length of lines . f Total length/size <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS " {1-"Depth Siz ---Number _ <br /> �` ..�..- <br /> SUMPS I-! Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ <br /> 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 Di%trict. <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 toibecome 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." 1 <br /> The applicant must c II or all req fired in Complete drawing on verse side. <br /> e _ <br /> Signd X ^fZ Title: Date: <br /> OR DEPARTMENT USE ONLY `� / <br /> Application Accepted by <br /> Date Area <br /> Date <br /> Pit or Grout Inspection by r ate Final inspection by ` <br /> Additional Comments: I <br /> ❑ Stir 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT RUE£ AMOUNT REMITTER CK °< RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH "': <br /> ♦.EH13-241REV.r/n51 <br /> EH 14-26 <br />