Laserfiche WebLink
APPLICATION FOR PERMIT ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 - <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. J1 <br /> V E 6 <br /> c• City&4 C Lot Size V PM <br /> Job Address q <br /> pp , <br /> u-kie r!�-ez Address t7 Z �v vl_ Pho ` <br /> Owner's Name <br /> 5��� Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL FI WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION EJ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL S/SUMPS <br /> � <br /> ATIONS <br /> file INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION Dia. of Well Casing V <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca el Excavation <br /> Type of Casing Specifications <br /> F1 Domesticl Private ❑ Gravel Pack ❑ Tr Type of Grout <br /> f'1 Public .w ❑ Other - Delta. Depth of Grout Seal <br /> I I Irrigation rox- Depth l i Eastern Surface Seal installed by__ # <br /> Repair Work Done Type of Pump <br /> "� aDone <br /> te Work <br /> H P �" StA <br /> Well Destr n ❑ Well Diameter Sealing ,Material Itop 50') <br /> Depth <br /> Filler Material I Below'50'i I _ -* <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION 1 iNailabPerw thin 200 feet.) titpublic sewer isInstallation will serve: ResidenceCommercial Othernits: � Number of bedrooms <br /> i Number of living u �-- - {Wateyablb depth <br /> ;� <br /> Character of soil to a depth of 3 feet: 41V T <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg y Method of Disposal <br /> PKG. TREATMENT PLT- ❑ l 1 <br /> Distance to nearest: "' Well Foundation Property Line <br /> . ! w Total length/size- <br /> LEACHING LINE 0 No. & Length of lines ,,.,, <br /> Foundation Property Lin <br /> FILTER BED » LJ Distance to nearest: Well �. <br /> s II• - - - � _ - -. <br /> . . ....�.... a ----4 <br /> SEEPAGE PITS_ I') Depth Size # Number . ■ ' <br /> SUMPS L1 Distance to nearest: Well 0g*Foundation — Property Line I <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 District. f ~ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in thelperformanca of the work for which this permit is issued, I shah not <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contraceonsrsub'ect torworing or �kman'lsgompensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> T licant m call for all re red ins ctions. Complete drawing on reverse side. <br /> r �` • -Title o Date: <br /> Signed X <br /> AOR DEPARTMENT USE ONLY <br /> 4. � Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date <br /> Final Inspection by Date <br /> f Additional Comments: 835.6385 r <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 0 Ma eca 823-7104 ❑ cY <br /> 'I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE iRECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> � AMOUNT DUE AMOUNT REMITTED C S}1 <br /> 3S U - b 7_a 317 <br /> + EH 13-24 IFIEV.t <br /> EH 14-20 <br />