Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. /f�� 2 <br /> (Job Address 'f" � A"`�- City Lot Size J b C� PM <br /> Owner's Na Address � /at��J <br /> �( Contractor 7�Address License No. Phone_ <br /> '\TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM EPAIR ❑' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL URE AL OTHER WELL PITS/SUMPS <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> ❑, �1 d-ustrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> F 0.mestic/Private ❑ Gravel Pack ❑ Tracy Type Casing Specifications <br /> F Public Cl Other ❑ Delta Depth of rout Seal Type of Grout--­ <br /> S <br /> rout __ g, <br /> I I Irrigation ..Approx. Depth I I Eastern Surface Sea nstalled by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material It <br /> 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AI REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is LA <br /> f"bbl available within 200 feet.) <br /> Installation will serve: Residence-4 Commercial_ Other -� <br /> Number of living units: ---t— Number ofbedroomsZ- ((� <br /> Character of soil to a depth.of 3 feet: ��c:rv.d w �, smz. Water table depth �Z�" <br /> SEPTIC TANK d Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well /00 Foundation Property Line !Sat j�1 <br /> LEACHING LINE No. & Length of lines U Total length/size v <br /> l inn <br /> FILTER BED 11 Distance to nearest: Well �0 Foundation 30 Property Line 130 <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll 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 'Di'trict. <br /> Home owner or licensed agent's signature certifies the following: "1 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 follow' : "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 C 'or a." <br /> The , plica u all for all required inspections. Complete drawing on r ar rse sidY/41,161"94ZAZ <br /> i° <Signed Title: Date: X 16,49 <br /> FO SE ONLY �` G <br /> Application Accepted by Date [ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH FRECEIVED BY DATE(� /�^PERMIT'NO. <br /> v.EH 13-24(REV.tix51 GJ F�'f �O, (fi [Q �j a�-q0 /,- ', Ci <br /> EH 74-28 V l�- <br /> �-ZO-p�- /vtgy n0�-'��e b-�.h i�r✓-�°c0��:� <br />