Laserfiche WebLink
r. <br /> APPLICATION FOR PERMIT <br /> SAN UOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r <br /> Job Address 1 I G�� U 2-6 City `;xleleLot Size�� LA'S PM <br /> L (� �� 7��' 249 Phone <br /> Owner's Name i Address f d <br /> Contractor r ��' l Address,�a �+ ,0 L NJe - License No.a 77 1_�Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS off <br /> Cl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing to <br /> X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S"f` Specifications ��' <br /> FI Public F] Other " Delta Depth of Grout Seal 1,40 , Type of Grout NCc[.r. <br /> I I Irrigation —.Approx. Depth i I Eastern Surface Seal lnstalled by - <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction OLD Well Diameter 1 I Sealing Material Itop 50'1 <br /> Depth 1��f�T t=iller Material {Below 50') re <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRIADDITION ( I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms n <br /> Character of soil to a depth of 3 feet: Water table depth (, r <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size , <br /> FILTER BED I] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( 1 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <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. <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 persons subject to workman's compensa- <br /> tion laws of California." . <br /> The applicant must cakl f l r quifed inspections. Complete drawing on reverseside. <br /> M <br /> Signed X Titley P,+" e-Sl�4f Date: <br /> .0 <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Date S " Area C) <br /> Pit or6 �ezpy Inspection by bate Final lnsp ction by N Date �� b <br /> Additional Comments: /�/n <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-71_ ­ ❑ Tr cy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AM UNT DUE AMOUNT REMITTED C K RECEIVED BY DATE e�P,E.RMIT NO. <br /> . EH 13-26 IREV.1 r 95) �� �5 � �s v� 7 <br /> EH 14-2t1 111 / 11F <br />