Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 1 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 welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Addressy Lok 1t7 yCf <br /> ��// a �Cn;Y L/ \ ot Sizr PM <br /> Owner's Na eC�l[CSAdd <br /> ress i �° hpT�l�] . <br /> h � Y Q, phone � <br /> Contracto fit~ .Address 3=1a �` � kcense No. "9V Z, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:-.SEPTIC TANK — SEWER LINES '' 3 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL� ` OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- <br /> Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 50') .j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence— Commercial'_ Other # n' d r <br /> Number of living units: Number of bedrooms r i t1 <br /> Character of soil to a depth of 3 feet: Water table depth `1 <br /> SEPTIC TANK I ❑ 'Type/Mfg Capacity � No. Compartments <br /> PKG. TREATMENT PLT. EJ _J <br /> Method of Disposal <br /> Distance to nearest: 'I Well 5 t Foundation--LProperty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size { <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size- Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CJ I µ !t <br /> I hereby certify that I have prepared this application and that the work will be�dohe in accordance with San Joaquin county ordinances,-state laws, and F <br /> rules and regulations of the San Joaquin Local Health District. <br /> '12 �- I­- III <br /> Home owner or licensed a nt'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 su manner as to become sub ' to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil owi certify that in the perfor -co the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Calif i <br /> Th u II for�iLra ction m le drawing on reverse id <br /> Signe Title: Date: <br /> OR DEPARTMEN USE ONLY / (� <br /> Application Accepted by Datf � re <br /> Pit or Grout Inspection by pate Final Ins^^—sten by Date�9b <br /> �Ad itional Comrlldnts: !ZQ-r to <br /> tk 466-6781 ❑ Lodi 3621 ❑ Manteca 623-7104 ❑ Tracy!'' <br /> App icant- Retuall copies to: E v'ron nt I Has P Init/So ices 1601 E..Hazelton Ave. P.O. Box?M, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO F f CASH a RECEIVED BY DATE PERMIT•NO. <br /> + EH 15-241RFV,1/e51 <br /> EH 14-28 <br /> I <br />