Laserfiche WebLink
- _.�.... <br /> APPLICATION,FOR PERMITJ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 1601 E. HAZE T ON AVE.,.STOCKTON, CAk �v <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1' YEAR FROM DATE ISSUED f t old <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 /> r made in compliance with San Joaquin Coun <br /> Local Health District. tY Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> r , <br /> Job Address City Lot Si <br /> e PM <br /> Owner's Name 1 rW <br /> Address �' .. <br /> J Phone <br /> Contractor 1 � �* <br /> vU G <br /> TYPE OF WELL/PUMP: Address NEW WELL E3 WELL <br /> Na. Phone <br /> WELL RE ACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO ❑ <br /> DISTANCE TO� NEAREST: SEPTIC TANK SY TEM REPAIR [I OTHER L3DISPOSAL FLD.FOUNDATION: SEWER LINE <br /> PROP. LINE <br /> INTENDED USE GRICULT E WELL OTHER WELL µ <br /> TYPE OF WELL PROBLEM E ��p��s/SUMPS <br /> ❑:Industrial CONSTRUCTION SPECIFICATIONS "` <br /> ❑ Open Bottom ❑ i <br /> ❑Domestic/Private ❑ Gravel Pack Manteca Dia. of Well Excavation❑ Tracy Dia. of Well Casing <br /> ❑Public ype of Casing <br /> ❑ Other ❑ Delta De of Grout Seal Specifications <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Type of Grout <br /> Repair Work Done ❑ Type of Pump Surfac \! Installed by <br /> � H.P. <br /> II Destruction ❑ Well Diameter / State Work Done_ <br /> Sealing Material {top 50'I <br /> DepthFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> CD <br /> Installation will serve: Residenceavailable within 200 feet.) <br /> Coercial Other <br /> Number of living units: A+�Num of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK �,OP- D Type/Mfg Water table depth N <br /> PKG. TREATMENT PLT. E2Capacity �_ No. Compartments "~ <br /> Distance to nearest: WeII Method of Disposal <br /> ,rte Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines t <br /> FF <br /> ILTER BED ID Distance to nearest: Well Total length/size <br /> r Foundation Property Line <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br />'i SUMPS ❑ Distance to nearest: WeII <br /> 1, 1DiSPOSAL PONDS L2Foundation Property Line - <br /> i <br /> 011 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 per it is issued, I shall not <br /> employ any person in such manner as to become subject to workman's cord <br /> certifies the following: "1 certify that in the Performance of the work for which thlsat1erm t on ssissuedof '1 losha I emonotractor's hiring or suh-contracting signature <br /> tion laws of California." p p y persons subject to.workman's compensa- <br /> The applicant mu r all required i Qns. Cmplete drawing on re se side. ; <br /> Signed X t r <br /> Title: <br /> Date: V <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> (J <br /> Pit or Grout Inspection b Date rea <br /> ate Final Inspection by <br /> Additional Comments: ,, ,. Date <br /> 1 '15❑ Stk 466-6781 ❑ L di 369-3621 ❑ anteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTEp <br /> RECEIVED BY DATE ,t <br /> 4 t PERMIT'No. <br />+ EH 13-24 1REV.t i a 51 <br /> EH f428 <br /> t <br />