Laserfiche WebLink
APPLICATION FOR PERMIT' f '� •r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rk <br /> is <br /> Application is hereby made to the San Joaquin Local <br /> lnce Health <br /> Distric for sewage or'No�1862 forcwe111dpump and the R/or install the res and hereindescribed. <br /> of the San'Joaqucation in <br /> made in Compliance with San Joaquin county <br /> Local Health District. <br /> City >A1®�r/1/ Lot Size PM <br /> Jab Address00 <br /> Phone <br /> Owner's Name w <br /> Address _ <br /> Ir :2���/—Phone <br /> Contractor Address 0 License No. <br /> IWELt REPLACEMENT ❑ DESTRUCTION 1)TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES �_--- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> g`Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout — <br /> 1 [=1 Other Cl Delta Depth of Grout Seal <br /> .,j i-i Public - <br /> I 1 Irrigation -Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> . > f_ } H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 <br /> Depth Filler Material iNo!Below 50'1 w <br /> sysm perm <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION l 1 DESTRUCTION I I availablerwi hin 200 fe tined if public seWi r;is <br /> installation will serve: Residence_ Commercial Other <br /> s'^' <br /> Number of living units: Number of bedrooms 4 ,r Water ta_b!e_depih_ <br /> '1 Character of soil to a depth of 3 feet. V No, Compartments <br /> `( SEPTIC TANK ❑ Type/Mfg Capacity <br /> e Method of-Di posal <br /> PKG. TREATMENT PLT. ❑_ Property tine <br /> \ Distance to nearest: Well Foundation <br /> Total length/size <br /> �` <br /> {� LEACHING LINE Y ❑ No. & Length of lines <br /> 1 Foundations Property-Lin. <br /> FILTER BED ID Distance to nearest: *Wel- <br /> .! M <br /> Size f `^'"�— Number ¢ <br /> SEEPAGE PITS I l Depth Property Line <br /> SUMPS Ll Distance to nearest: Weil Foundation p Y y <br /> d <br /> DISPOSAL PONDS ❑ <br /> I hefeby 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 03trict. '11.' <br /> o <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance f 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. Contractors hiring or sub contracting signature <br /> ! •9 certify that in he performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the following: <br /> k tion laws of California." <br /> The applicant m t cal r all ired inspections\Complete drawing on reverse side.; 4 <br /> Title: Data: - <br /> Signed <br /> I FOR DEPARTMENT USE ONLY <br /> Area <br /> �j <br /> f ' Date J <br /> t Application Accepted by <br /> fiDate Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> i 1 ElS4k 466-6781 17 Lodi -369-3621 ❑ Manteca 623 7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permiit`/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Y FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO MOUNT DUE AMOUNT REMITTED' CASH 2 /� // <br /> EH 13-24IREV.I/x5] 66 p���ry �`J/" / V�I <br /> S' r7 <br /> ,� EH 14-26 <br />