Laserfiche WebLink
f <br /> APPLICATION FOR PERMIT <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby 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. <br /> r�l <br /> Job Address Q I y 0,4 rL _ r City Lot Size /2— 76PM <br /> fl T <br /> Owner's Name Address 22Q /t/, Phone <br /> Contractor T 1 �L t Address r 446A License No. ! 3 CL9 7 Phone <br /> ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION — "t AGRICULTURE WELL OTHER WELL PITS/SUMPS II <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II <br /> .i <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑"Domestic/Private ❑ Gravel Pack EITracy r Type of Casing Specifications ! <br /> 1-1 Public I-11 Other {71 Delta f Depth of Grout Seal Type of Grout <br /> I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by !! <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing-Material (top-50')— II <br /> I. <br /> �+ Depth Filler Material (Below 50').,,* <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION rk REPAIR/ADDITION-1 1 DESTRUCTION I 1 INo septic system permitted if public sewer!is <br /> I+ "` available within 200 feet.) 1! <br /> Installation will serve: Residence Commercial_ ther <br /> II <br /> Number of living units: __ ��, Number of bedroom <br /> i Character of soil to a depth of 3 feet: ` " Water table depth i! <br /> t-� SEPTIC TANK /Mf p J�� Capay Na. Compartments °I <br /> PKG. TREATMENT PLT. ❑ a <br /> � ` ,. r Method of Disposal <br /> # Distance to nearest: Well �� / ° Foundations Property Line 1-7— <br /> LE <br /> -7 , <br /> LEACHING LINE No. & Length of lines AZ 4��.� /� Total length/size II <br /> FILTER BED ❑ Distance to nearest: Well�� Foundation' Property Line 11 r <br /> I <br /> t — <br /> SEEPAGE PITS Depth S Size F Number <br /> SUMPS LI Distance to nearest: Well -'FoundationProperty Line I <br /> DISPOSAL PONDS U <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 Dijstrict. t­t, IN MI <br /> Home owner or licensed agent's signature certifies the following: "I{cefrtify 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 wurkmah's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 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 Californi <br /> The appliea o d inspe3 ti S. Complete drawing orever a Sid . <br /> : � <br /> Signed X I R Title: C12Date: <br /> FOR DEPARTMENT USE ONLY !� <br /> � j II <br /> A lication Accepted by ' Date _ Area <br /> Pi r Grout Inspection byDat ® <� Fi al Inspection by Date <br /> � - <br /> Additional Comments: <br /> ❑.Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-6385 it <br /> Applicant - Return all copies to: Environmental.Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �! <br /> '! it <br /> ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT-NO. <br /> +.EH13-24 1 REV,r i H 51 <br /> 4-26 <br />