Laserfiche WebLink
- 1 <br /> �j�Lr' APPLICATION FOR PERMIT �- <br /> � ff <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160VE—HAZELTOWAVE., STOCKTON,.CA <br /> Telephone (269) 466-6781 <br /> KJ 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 Addressr <br /> o�-- -r IZ City 1` Lot Size L <br /> _ maPM <br /> 11' - <br /> Owner's Name 1� C�[YJ00 "M Address -r ' "+yr�yoPhone j <br /> ., 0 <br /> Contractor Address License No.��Phone <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION 71 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Le-s-va &fl y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES€ DISPOSAL FLD. PROP. LINE v <br /> FOUNDATION AGRICULTURE WELLQTHER WELL LIMPS <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 d Af 4J Specifications f <br /> Cl Public [.Other �+� ❑ Delta De th of Grout Seal s <br /> t a.. f P Type of Grout <br /> ❑ Irrigation � Approx. D th ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ;Type of PumpH.P. tti I State Work Done, _ <br /> R <br /> Well Destruction Well Diameter= Sealing Material Itop 50') �P.MQ.t1�QhnCL.�%�1(14tU <br /> Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK:_NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ Wo septic`sgstem permitted if public sewer is ! <br /> i w„ 4 available within 200 feet.) ! <br /> Installation will serve: Residence­ Commercial *_ Other <br /> Number of living.units: Number of bedrooms , r .a <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 nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. Si Length of lines Total length/size'` f <br /> FILTER BED ❑ Distance to nearest: Well }Foundation Property Line <br /> "33 � <br /> " aS?EPAGE PITS' ❑ Depth Size 1 Number` <br /> SUMPS ❑ Distance to nearest:-'" "WellFoundation i'` Property Line <br /> y <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 orainances,,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 fallowing: "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 applicant m st C911 for all required€inspections. Complete drawing on reverse side. y' <br /> f. <br /> t <br /> Signed l Title: <br /> %*, FOR DEPARTMENT USE ONLY u G RIC iTf Application Accepted by Date- / y �Ar � <br /> Pit or Grout Inspection by pateavl'� Final Inspection Date <br /> rtio 0 e <br /> r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mane 823-71 ❑ Tracy 835-6385 (�/ <br /> applicant- R tuxn all copies t nvironme tal Health Permit/Services 1601 E. Hazelton A e., P. Bax 2009 5tk., CA 5201 �r_ _� ;. <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> r INFO GASH p <br /> + EH 13-24 IREV.1iR51 <br /> EH 14-26 , � . <br /> J <br />