Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> a <br /> PERMIT EXPIRES 1.YEAR-FROM DATE ISSUED <br /> +-3(Complete.in Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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. t <br /> i <br /> // r <br /> Jab Address Cit <br /> � � / _ y � Lot Size_.S�lc� PM <br /> Owner's Name Address ,Phone h <br /> Contractor's Name _ License No. <br /> o�{�-�/-- C Phone 9 —E97 7 <br /> TYPE OF WELL/PUMP: NENArwuLL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR G OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <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 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Number of living units./__Number_of.bedrooms �_ a <br /> Character of soil to a depth of 3 feet: `Water table depth— Z`Lr <br /> SEPTIC TANK ❑ 7 e/Mf 1 . <br /> Type/Mfg 9 Capacity-1fx� No.-Compartments <br /> PK G. TREATMENT PLT. ❑ P i Method of Disposal Y c F <br /> Distance do nearest: Well Oe Foundation Property Line ^� <br /> LEACHING LINE No. & Length of lines =_ -7a r <br /> 9 a o' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ' Depth w u h Size 2- Number .� <br /> SUMPS ❑ Distance to nearest: Well li2O " Foundation _ Property Line_%S <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 Jbaquin 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 following: "I certify that in the performance of the work for which this permit is issued,I shall employ persans'subject to workman's compensa- <br /> tion laws of California." 1 <br /> The,applicant must cal r all required ictions.-C plete-drawing-on-reverse side t - <br /> ' <br /> Signed €h w,Title: j� � Date: -.l W <br /> .t FOR DEPARTMENT USE ONLY <br /> e. Application Accepted by / bb Date S .Area 07 - <br /> Pit or Grout Inspection by Date ! t7� Final Inspection by bate <br /> 1/Z 13 <br /> dditional Comments: $ A" <br /> 12Mk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> ` EH 1426 {{{ <br />