Laserfiche WebLink
' APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� + <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � <br /> Telephone (209) 466-6781 P <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby 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 <br /> Job Addres City /� Lot Size PM 33 i <br /> /15 Owner's Name rti4 Address Phone -- !S' <br /> 1-� .-.,... .......�.r..r.,.�.,--..,ti....., ,.m..r - �..i.a,: . <br /> Contractor Addres License-No. �r Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSITALLATtONX. SYSTEM REPAIR ❑ OTHER 0 i <br /> DISTANCE TO�NEAREST: SEPTIC TANK - SEWER LINES �- 'DISPOSAL FLD. ` PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS JD(J <br /> INTENDED USE TYPE OF WELL = PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS �f <br /> © Industrial - C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private All ravel Pack ❑ Tracyv� Type of Casing •r Specifications <br /> 57 <br /> (1 Public Cl Other Delta Depth of Grout Seal :E540 '`" Type of Grout <br /> 'a, <br /> 1 1 Irrigation _-Approx.-Depth I I Eastern Surface Seal Installed by 5J - <br /> Repair Work Done ❑ Type of Pump ---15,L/1'�t� H.P. ' - State Work Done I <br /> Well Destruction ❑ Well Diameter': "�Sealing Material Stop 501 t <br /> DepthFiller Material (Below 501—� - - - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION (.1 DESTRUCTION I I (No septic system permitted if public sewer is C <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity— No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i i <br /> Distance to nearest: Well Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED .❑ Distance to nearest: Well Foundation Property Line 1 <br /> SEEPAGE PITS W i I ,Depth Size Number f <br /> SUMPS L-1Distanceto nearest: Well Foundation Property'L`ine', i <br /> DISPOSAL PONDS V` <br /> v J - <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. ­C­& <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,t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica all requ' ctions. Complete drawing on rave se side. <br /> Signed X Title: ' Date: <br /> FOR DEPARTMENT USE NL'Y <br /> Application Accepted by ~Dat,e5 ZIP Area L <br /> Pit or Grout Inspection by Date Final Inspection by Date's i <br /> h <br /> Additional Comments: Q <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 b Manteca -7104 ❑ Tracy 835-&%5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2t0,(18, Stk., CA 95201 <br /> i )NFO AMOUNT DUE AMOUNT REMITTED.3 CASH RECEIVED 6Y DATE IT'NO. <br /> +.EH 13-244REV.i/x5) to <br /> EH 14-2e <br />