Laserfiche WebLink
y APPLICATION FOR PERMIT <br /> SAN JOAQ.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 /> 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 City G r Lot Size r <br /> I PM5-17V <br /> ^ <br /> Phone <br /> Owner's Name Address p 7 sriLf'— 2 "LJ l 7 V <br /> f1 — - r / p <br /> Contracti l.C� Address 100. GJ Gf License No 19 6 Phone, CAo S�d.� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .F 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 ti <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Workbone ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No,septic system permitted-if:public sewer is 6 <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of. oom _� f �b <br /> Character of soil to a depth of 3 feet: :- Water table depth d �r <br /> SEPTIC TANK ❑ T ^' F <br /> ype/Mf9 � Capacity No. Compartments � <br /> PKG. TREATMENT PLT. ❑ c Method of Disposal <br /> Distance to nearest: Well___.___Lr0undaVon Property Line ' <br /> .L • <br /> LEACHING LINE I No. & Length of lines Total length/size K <br /> FILTER BED LlDistance to nearest: Well _so Foundation r Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> 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 applicantmst call If II re fired inspections. Complete drawing on revers Date: <br /> sid <br /> Signed Title: 1� t� g <br /> ,L[� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date d Area <br /> Pit or Grout Inspection by Date Final Inspection by pate �d <br /> Additional Comments: U /,,C_A,—, <br /> Z4/7, 7'h 7w, - <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 8234104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 i66-A e,- <br /> ; <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> + EH13-24(REV.$/a 5)4-281117 <br /> EH 1 �' <br />