Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> .r .AV <br /> PERMIT EXPIRE-S.1 YEAR FROM DATEISSUED <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 /> �V J s l fy.a-' Y } tYl� �'1 C 14►R1 Size "PM <br /> Job Address —-_ b„ r ES Ci t� <br /> Owner's Namesk� Address I _ Phone <br /> 1 � P <br /> Contractor�1,PE LTHAXA—CQ 4-S 14ddress 43 �5 Wr C..L -f C3 License No., )_LPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑_,,- <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ L. f OTHER ❑ <br /> DISTANCE TO NEAREST:"SEPTIC TANK.s s SEWER LINES DISPOSAL FLD- PROP. LINE <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private _l ❑)Gravel Pack ❑ Tracy Type of Casing r .:'� I Specifications <br /> ❑ Public f4 <br /> es. ❑ Other, 'f jy t" T�;O.Deita�yf <br /> J •Depth ofGmut Seal,—./ Type o'Grout <br /> � <br /> Ed Irrigation Y'4I� --_-1pprox. Depth : ❑ Eastern Surface Seal Installed by, <br /> Repair Work Done ❑ Type of Pump H.P. '#State Work Done 4 <br /> Well-Destruction ❑ Well Diameter Sealing Material ftop 50') ` <br /> r <br /> Depth', I Filler Material (Below 50'174VV '� V <br /> TYPE'OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I l r` available within 200 feet.)y <br /> Installation will serve: Residence_L­1�6-mmercial Other 1 <br /> Number of living units: _1 Number of b edr4ffs l v <br /> Character of soil to a depth of 3 feet: �Ry Water table depth <br /> SEPTIC TANK ❑ Type/Mfg L _!'1}��C V��i f �7 _ Capacity �. No. Compartments <br /> PKG. TREATMENT PLT. ❑ a 1 Method of Disposal <br /> I r__ . ; L <br /> ! Distance to nearest: Mall t Foundation3 Property Line r <br /> LEACHING LINE ISG: & Length of lines r d Tat 1 length/size r <br /> k 3... <br /> FILTER BED ❑ Distance to nearest: Well a--.-Foundation d1 -t PropertyLine <br /> I,4. <br /> SEEPAGE PITS ❑ Depth Size y 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 /> eany person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifie a following: " ertify 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 Nalifornia." <br /> The applican tcall <br /> for lire ired pecti s. Complete drawing o verse side <br /> Signe _ Title: G Date: <br /> FOR DEPARTMENT USE ONLY <br /> AbzApplication Accepted by Date Q—�`r` Area <br /> `Pit or Grout Inspection Date •+° Final.Inspection byy Date O <br /> t Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3626-3Cl MaRitaie 823`7104 ❑ Tracy835-6385 " <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O.',Box 2009, Stk., CA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTED CK :RECEIVED BY DATE PERMIT'NO. <br /> INFO �) <br /> + E <br /> H M24 MEV. 5) /r 1 �� ��. f�'l <br /> EH 14-28 i V t �l 1 1 l <br />