Laserfiche WebLink
f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE.; STOCKTON, CAS' <br /> Telephone (209) 466-6781 i'•iH; 1980 <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. <br /> Job Address 3/a8�t '5� 33 City Lot Size PM <br /> Owner's Name Greo� Address •�^`�v"t" Phone <br /> e r� zj S ` l ���T�tf, <br /> Contractor, ®4� -c ``.- <br /> Address D /� ��fL License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P_U.MP INSTALLATION ❑ '" SYSTEM REPAIR M", ' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK--_�5 - --SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL— OTHER WA=LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing + <br /> P(Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other C] Delta Depth of Grout Seal Type of Grout— <br /> I I Irrigation —,.Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done ik Type of Pump �_ H.P.' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing aterial (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is <br /> availablewithin200 feet.) <br /> Installation will serve: Residence_ Commercial7�- Other 0I <br /> .0 <br /> KFtimber of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg -�­=Capacity No. Conipartments <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 ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line LV <br /> DISPOSAL PONDS ❑ �JJ <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. N. <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 mu call for all Fequired inspections. Complete drawing on reverse side. <br /> Signe �--®' Title: - Date: r <br /> FOR DEPARTMENT USE ONLY Q� <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EHi3-24(REV.1/95) <br /> EH 14-26 J <br />