Laserfiche WebLink
f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN 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 instail 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 1009:346 Z' -'J" hnotl�� City /�5� Lot Size PM <br /> 1 <br /> I Owner's Name CAq L-t-l Address 4?13! 4M re-fPC-_L b Phone gra <br /> Contractor F�'4;!YJ iZAC O_X:r Address , 7 Y, AC�­ License No.WV?��X74_ _Phone (14r,3!7 ' <br /> TYPE OF WELL)PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR, ❑ OTHER © C .t <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI L FLD. PROP. LINE �1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications- <br /> ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _Appy Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of ump H.P. State Work Done_ <br /> + Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> Depth Filler Material iBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRJADDITION - - DESTRUCTION H (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 1-1/Commercial_ Other <br /> Number of living units: _I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: SA Ai b Water table depth <br /> SEPTIC TANK ❑ Type/MfgLe fc i e grad t,- rapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property-.Line <br /> Fi0c <br /> LEACHING LINE F4--"No. & Length of lines I `�� Total length/size4 r <br /> FILTER BED ❑ Distance to nearest well �� r Foundation zor Property Lineoi__ <br /> Fo SEEPAGE PITS I'1 Depth 12- 1 Size X t$ Number <br /> SUMPS Distance to nearest: Well Ia0 Foundations r Property Line . <br /> FDISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin cbunty ordina�lces, 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 /> i <br /> The applicant must call for all required inspec'ons, Complete drawing on reverse side. <br /> .� i <br /> Signed X Title: 'i(/ ti Date: '"+ 7F1 + <br /> 0 FOR DEPARTMENT USE ONLY <br /> - S� 3 <br /> Application Accepted byt✓.>P.i"v Date Area <br /> F! Pit or Grout Inspection by Date Final Inspection by Date <br /> JAdditional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMITN0. <br /> +-EH 13-I4(SEV,1/r;5) s �{ <br /> EH 14-29 { c.J <br />