Laserfiche WebLink
1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1_YEAR_FROM DATE_ ISSUED r <br /> ~ (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a perrnrt to construct andlor enstail 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/purnp and ore Rules and Regulations of the San Joaquin j <br /> Local Health District <br /> Job Address _..�✓ f--�'..— � — ` --.�_—_ City --.—. 1 nt Size 7 PM --.— f <br /> _-., Owner's Name �o�=_ ��� -- _.Adr3ress ��✓I-�r� .��--�Phoner /�„r �O� — <br /> Contractor L' >�'. — Address . ! License No. <br /> TYPE OF WFLLlPUMP NEW WELL " I WF.LL'.REPLACEMFNT f DESTRUCTION Li <br /> PUMP INSTALLATION i) SYSTEM REPAIR F) OTHER 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ — — SEWER LINES r — — — DISPOSAL Fl D.— — _ PROP. LINE _-- <br /> - FOUNDATION —. — — AGRICULTURE WELL _ — OTHER WELL—.. — _ PITS/SUMPS <br /> INTENDED USE TYPE_OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 1-1 Open Bottom L: Manteca Dia. of Well Excavation--_— — .— --. Dia of Well Casing — — — <br /> M Domestic/Private i-1 Gravel Park U Tracy Type of Casing_ — — — — -- Specifications <br /> Public I Other fl Delta Depth of Grout Seal — — -- — Type of Grout. <br /> imefatum Approx. Depth 1 Eastern Surface Seel Installed by <br /> Repair Work Done I I Type of Pump _ — —,._ H.P.._­! — State Work DoneWell Oestruction i- Well Diameter -_—— Seating Material 1110P- -11 <br /> Depth�_ —_ _ Filler Material (Below <br /> TYPE OF SEPTIC WORK NEW INSTAL 1ATION REPAIR/ADDITION I DESTRUCTION I (No septic system permitled It public sewer s <br /> tt` available welhrn 200 feet.) <br /> installation will serve: Residence Goin rc1al —_ Other _ — -_ Ju <br /> Number of living units. — Number of bedrooms -� — ,}✓) <br /> Character of soil To aXF-IjMethod <br /> of 3 feet: _ �� --��q 9_ —Water table depth_ <br /> SEPTIC TANK Type/ <br /> Mfg Cat>acit,�L���(— No. Compartments _ — -- — <br /> PKG. TREATMENT Pkof Di salDisposal <br /> Distance to nearest: Well�l� f.._ Foundation' _ rProperly Liner - <br /> - — — — �- J-v �- <br /> LEACHING LINE No. & Length of lines Total length/size-17Q-y-2—. — — — — <br /> FILTER RED i-1 Distance to nearest: Foundation Properly Line <br /> Line <br /> SEEPAGE PITS X1. Depth — —Sire - — — -.— Number <br /> SUMPS I l Distance to nearest: Well — — _ Foundation — — —. Property Line — — — <br /> DISPOSAL PONDS IJ } <br /> I hereby certify that 1 have prepared this application and that the work will be done u1 accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District, -- ------ -^� �" <br /> Home owner or lrcensad agent's signature certifies the following. "I certify that in the performance of the worts for which this permit 1s 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 subcontracting signature <br /> certrfres 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 Californi <br /> f The ap 1 _st epi/j�r all r it in ons. Cr r to drawing on reverse side <br /> / - <br /> Title: �i .r <br /> Signed <br /> s <br /> FOR DEPARTILIENT !!S ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by — Date — - at fns ctr n by `. — — Date <br /> _ — _ . <br /> Additional Comments: <br /> n Stk 466.6781 � C] Lodi 369-3621 G Manteca 82f7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies W Environmental Health Perrtwt/Services 1661 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95401 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASit RECEIVED BY RATE PERMIT'NO r <br /> EH 13-74(REV.1,w D: 9 <br /> IN 14-M <br />