Laserfiche WebLink
APPLICATION FOR PERMIT 4 �., <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I' n <br /> 1601 E. HAZE4TON AVE.,.STOCKTON, CA R Y <br /> "Telephone (209) 466-6781 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t7- <br /> (Completer <br /> 7.{Complete in Triplicate) <br /> ' e or No. con fort and/orell i and the Rules and Regulations of the San Joaquin <br /> reb made to the San Joaquin Local Health District se�nra permit to construct and/or install the work herein described. This application is <br /> Application is he y , <br />{ made in compliance with San Joaquin County Ordinance No.549 o C T f ,� ¢ e' <br /> 'Local Health'District. *II� a „- #(� PM <br /> e S/�3 /IQ of Size <br /> City . <br /> Job Address - i!� r1l Phone <br /> _ Cr <br /> :I1 Address l <br /> j Owner's Nair Phone <br /> License No. <br /> jAddressDESTflUCTION Cd <br /> Contractors WELL REPLACEMENT ❑ <br /> II NEW WELL ❑ OTHER ❑ <br /> TYP­EO WELL/PUMP: !I SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. POOP. LINE <br /> i + SEWER LINES �— PITS/SUMPS <br /> i DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION — <br /> INTENDED USE ��TYPE OF WELL` PROBLEM AREA CONSTRUCTION SPECIFICATIONSDia. of Well Casing <br /> ' d Manteca Dia. of Well Excavation <br /> ❑ Industrial ii Open Bottom Specifications <br /> ❑ Tracy Type of Casing <br /> d Domestic/Private ❑ Gravel Pack - -- Depth of Grout Sea! Type of Grout <br /> '+" p Delta f� <br /> i '❑ Public ❑ Other j Surface Seal Installed by <br /> 4 ❑ Irrigation iM —Approx. Depth ❑ Eastern k. State Work Done — <br /> "I• H.P. <br /> Repair Work Done ❑ Type of Pump t' <br /> rial (top 50'1 <br /> Sealing Mate [ <br /> Well Destruction El well Diameter ��- Filler.Material )Below 50'1 <br /> + Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK::11, INSTALLATION ❑'nREPAIfl1ADDITIDN Cl DESTRUCTION Mo septic system permitted if public sewer is <br /> III .,?i `r Others ri <br /> Installation will serve: ResidenceGtimmerciaj, <br /> + Number of living units: 'I� Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: "' Capacity No: Compartments <br /> SEPTIC TANK C7 Type/Mfg t Method of Disposal <br /> it -yam <br /> PKG. TREATMENT PLT. ❑ Property Line' <br /> Distance to nearest: Well Foundation p <br /> * Total length/size_ <br /> LEACHING LINE No. & Length of lines Property Line <br /> Well -�Fourldabon P rty M <br /> FILTER BED. D Distance to nearest: ✓ <br /> +❑ Depth Size Number <br /> SEEPAGE PITS -. Property Line <br /> SUMPS pd: Distance to nearest: Well - Foundation <br /> DISPOSAL PONDS iI❑ <br /> I hereby certify that I have prepared this application and that the work will be done;n 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: "1 certify that in the performance of the:work for which this permit is issued, i signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's os ' <br /> nsesubject to workman!sring or sub-contractngompensa <br /> I certifies the following:-I certify that in the performance of the work for which this permit is issued, I shall employ p <br /> II tion laws of California."�� ° <br /> i <br /> The applicant ust c fo II u' i pections. Complete drawing on reverse side. _ <br /> Date: <br /> Signed Title: <br /> ' FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted b� <br /> G4 pate Final Inspection b <br /> Pit or Grout Inspection Iby _ A <br /> Additional Comment <br /> ❑ Stk 466-6781 i s Lodi 369-3621 L1.Manteca 823-7104 C1 Tracy 835-638 Stk., CA 95201 ` <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK# RECEIVED BY' DATE PERMIT NO. <br /> FEE II� AMOUNT DUE- AMOUNT REMITTED CASH <br /> INFO �u{ c�7yl r 7 ] 7 17 <br /> + EH 13-24(REV.+/A5) / F i. <br /> EN 14-25 <br />