Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 n the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made H compliance with San Jaa in County for N .549 fsr sewage or NoA�l . 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,9/��/ <br /> Job Address K . R f <br />� r � ize PM <br /> fOwners Name - <br /> Address <br /> f <br /> Contractor Phon <br /> Address <br /> TYPE OF WELL/PUMP: NEW WEL License N Phone 22 !9 <br /> PUMP INSTALLATION p WELL REPLACEMENT 0 DESTRUCTION Cl <br /> DISTANCE TO NEAREST; SEPTIC TAMC �� . SYSTEM REPAIR ❑ OTHER 1+ + <br /> -- � r _ SEWER L1NE5 40 �,,.DISPOSAL FED. 1QP <br /> FOUNDATION AGRICULTURE WEL � DE <br /> INTENDED USE TYPE WELL-_ PITS/SUMPS <br /> TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ~"— <br /> ❑ Manteca Dia. of Well Excavation �i <br /> C:i�Pmestic/Private Gravel Pack ❑ Trac Dia. of Wel! Casing <br /> n Public <br /> f-1 Othe y Type of Casing <br /> 11 Delta Specifications <br /> I i Irrigation p Depth of Grout Seal l <br /> � prox. Depth I ! EasternSuface Seal Installed by Hype of <br /> ❑ Grou �/�i <br /> Repair Work Done Type of Pump <br /> Well Destruction Sealing..MateriaF(top 50')r <br /> ❑ Well Diameter ealState Work Done <br /> Depth Filter Material (Below 50') (V ► <br /> TYPE OF SEPTIC WORK: MEW tlVSTALLATIQN 1.1 REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is '� 1 <br /> Installation will serve: Residence_ Commercialavailable within 200 feet.) <br /> Number of livingunits: -- Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> M SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT,0 Capacity� No. Compartments ' <br /> Distance to nearest: Well Method of Disposal t <br /> Foundation Property Line <br /> LEACHING LINE ❑ ' No:& Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS l'I Depth <br /> Size Number <br /> SUMPS <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS Foundation Property Line <br /> 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. <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: 1 certify that in the Performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> p <br /> The applicant ust call for all requir i Pections. Complete drawing on averse s"de. <br /> f <br /> Signed t(, <br /> y Title: f< Q.,0 _ Date:�� <br /> FOF1 DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date `.J Area <br /> Pit or Grout Inspection by Date <br /> Final inspe tion by <br /> Additional Comments: —a, Date <br /> � ' ti �./l@ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton 835- <br /> Applicant <br /> ox 2009, ik., CA 9 1 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED, <br /> INFO C SH RECEI ED by DATE <br /> PERMIT'NO. <br />+-Eti 13.241REV.ria5) /i� 11y2- <br /> Eli 14 2ti C.41 9S L3 ' 1 �/� <br />