Laserfiche WebLink
� tEr caw �* , <br /> APPLICATION;FOR PERMIT <br /> e SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> -Telephone(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS UED �r�s <br /> _:.t;j, M .(Complete in Triplicate) .F ;4 �Ev.� , Z?(Al <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 /> Jljr <br /> Job Address "'z <br /> City Lot Size. PM <br /> Owner's Name" 'Address �� ISMF <br /> Phone �Z"�73 <br /> Contractor_(� 11-A V I-t s e/ j Ad� pZ-111A < �c.� it nse No: 6} y <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ " OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. `-j , PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> s <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca t Dia. of_Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac t <br /> Y Type of Casing Specifications <br /> ❑ Public L3 Other ❑ Delta Depth of Grout Seal ` <br /> s <br /> ED Irrigation of Grout <br /> Irrigation __Approx.�Depth LJ Eastern �Surfaca Seal Installed by 'r- <br /> Repair Work Done ❑ Type of Pump H.P. i"f State Work Done_ �hh . <br /> Well Destruction ❑ Well Diameter' Sealing Material (top"50') <br /> Depth i Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r <br /> "�" �` available within 200 feet.) <br /> Installation will serve: Residence—L-f< Commercial— Other <br /> Number of living units: Number of bedrooms 1Zi~ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg Water table depth (> ? t <br /> � L- �� -�; f d <br /> Capacity Z d!� No. Compartments Z <br /> PKG. TREATMENT PLT.Q " <br /> k Method of Disposal X <br /> Distance to nearest: Well _4eiO !t. Foundation O <br /> �- ?� Property Line_Z_zr� � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size G�3 <br /> FILTER BED Distance to nearest: Well Foundation pro � �. � <br /> Property Line Z4,� I <br /> f � <br /> SEEPAGE PITS- 0 I IL r <br /> ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line 6 <br /> DISPOSAL PONDS ❑ i <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, acid <br /> rules and regulations of the San Joaquin Local Health District. i <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 <br /> tion laws of California." P P Y Persons subject to workman's compensa; r <br /> The applicant must call for II required inspe ions. Complete drawing on reverse side. <br /> a Signed X— Title: _ — <br />