Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT <br /> SAN J.OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.��EL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1� ' ' (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. a <br /> e+,� <br />' Jab Address � ��� � City J � � Lot Size t 5n X 10q_ PM <br /> rPhone ON <br /> Owner's Name \!Oe L © � � Address <br /> Contractor_ <br /> OM PTO 11, c011 S Address Cvd Lai License No.V6-7 to.f-1-Phone J(1,7­9V;? <br /> TYPE-OF WELL/PUMP;' NEW WELL ❑ WELL REPLACEMEWr ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST 4SEPTIC,TANK­t� SEWER-LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED US£I TYPE OF WELI-mm"PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E'�xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 00'111 ❑•Tracy —Type of Casing Specifications <br /> ❑ Public Cl Other J7.Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done 1 <br /> N •_ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50 fh, <br /> � Depth <br /> Filler Material {Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑, DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I�. Installation will serve: Residence��"rCommerc61 "*""Other- <br /> Number of living units: f- Number of bedrooms <br /> Character of soil to a depth of 3 feet: � # Water table depth R <br /> I SEPTIC TANK Type/Mfg Capacity b0 No. Compartments <br /> PKG. TREATMENT LTi ❑ Method of Disposal <br /> Distance to nearest: Well Fou dation Property Line „+ <br /> } #} � 0 ds <br /> LEACHING LINE V No. & Length of linesI. �I-JQQ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundatiors' Property Line LLL <br /> SEEPAGE PETS Depth ' p`•Size G ; Number <br /> k �"_ ti <br /> SUMPS ❑ Distance to nearest: Well I Fouandatiofrn Property Line i" <br /> DISPOSAL PONDS ❑ L %W <br /> I hereby certify that 1.have prepared this application'and that the work will be done Ian accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation4Kof,the San Joaquin Local Health'Districts [ <br /> Home owner or licensed.agent's signature certifies the following: "I certify that in tht 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 followinkg:"I certify that in the performance of the work for which tfiis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus fl for all ed inspections. Complete drawing on reverses' e. <br /> Signed � Title: � ��? Q Or- Date: /- 29 <br /> FOR <br /> - 29FOR DEPARTM ENT E ONLY, e <br /> Application Acce to b f Date r Area <br /> APP P y fJI <br /> ' Pit or Grout Inspect by Date �d s Final spection by Date <br /> Additional Comment: _ <br /> .. -- <br /> i C] 5tk 466-6781 ❑ Lam-369-362T" ❑`Manteca 823-7104 ]Tracy 8350M <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE— AMOUNT REMITTED <br /> I CCACSH RECEIVED BY j DATE PER <br /> MIT"NO. <br /> + V 1324(REV.1/a 57 INFO ,�/ - ?/ 55 <br /> 977"1 <br /> 2b <br /> 4 EH 14-26 <br />