Laserfiche WebLink
s <br /> t. APPLICATION FOR PERMIT <br /> I'l X41 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />`a 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 /> r' Local Health District. <br /> Job Address Q C <br /> ) ity �'0ot Size PM <br /> +�y( 1 <br /> Owner's Name !\ lam u l—tet `h Address O 5� V V� �ne +�+� <br /> k l <br /> Contractor ddress License No (00 Phone <br /> TYPE OF OF WELL/PUMP: NEW WELL�( WELL REPLACEMENT ❑ DESTR CTION ❑ <br /> PUMP INSTALLATION �.)SYSTEM REPAIR IDr OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK �r SEINER LINES' �. w DISPOSAL FLD PROP. LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'` CONSTRUCTION SPECIFICATIOP49. 11 <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. at Well Excavation Dia. of Well Cal U <br /> Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications , <br /> Public Other M Delta Depth of Grout Seal Type of Grout � _ <br /> 1,1 Irrigation I K",_.-Approxi Deh. f�12 Ea,stern !!Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H.P. l L+ State Work.Done �S'���r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewerist available within 200 feet.) \ <br /> vInstallation will serve: Residence t Commercial— Other <br /> Number of living units: Number'of bedrooms s v <br /> Character of soil to a depth of 3 feet:' , t R <br /> Water table depth. <br /> 4i ❑ <br /> SEPTIC TANK ❑_ Type/Mfg Ca <br /> pacit f V <br /> t _ L �__ No. Compartments .. r �J <br /> PKG. TREATMENT PLT. -., "�'-" <br /> Method of Disposal <br /> i Distance to nearest: Well ✓ `�' .=' Foundation r Property Line I <br /> LEACHING LINE Ci No. & Length of lines. Tbtal length/size i <br /> FILTER.BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 13 Depth t Size a I <br />\ SUMPS ❑ Distance to nearest: Well Number <br /> _ 'Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thi.§application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reg ations of the San Joaquin Local.Health District.. <br /> Home owns o '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 er on in suc neer as t`o',be ma subj t to workman's compensation laws of California."Contractor's hiring or sub contracting signature ; <br /> certifies the to-111 wing: "I erti tat in orman of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws ofifomia.' 1 l <br /> The , plica s a f r`all r ire in t' ns. mplete drawing onireverse side. <br /> Signed aTitle: Date: a ' <br /> FOR DEPARTENT USE ONLY (� f <br /> Application Accepted by __ + Data <br /> 4 — <br /> Pit or rout lns�ection by Date �s Final Inspection by Date G <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.D. Box 2009, Stk., CA 95201 ; <br /> .A.r INFO A MQUMT,Dl3E AMOUNT REMITTED ASH r RECEIVED BY DATE PERMIT-NP. <br /> l _`�}�( �9 13 Sb <br /> t.EH 14-M IREV.i/x 51 k J, �EH 1 <br /> w�V ` <br /> J r <br />