Laserfiche WebLink
�. ✓s sl� ♦� rx' k. - - - .. 4i. 'm^ yl-xY"� s:.ti. � • .. 'w 1 ��..-�>t,p �.�, <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEf.TON AVE., STOCKTON, CA i <br /> Telepha:,- '2091 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 mrmit to construct and/or install the work heroin desations f t e San Joaquin is ' f, <br /> i� <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 Joegwn <br /> Local HEeI<h District. r <br /> c ^ l n <br /> Job Address � 3I k �f�Q`-" City Lot Size PMr. s ?$r <br /> —_r '" tXto 4i <br /> e . V �A r _ Address �rn Phone <br /> Owner's Nam <br /> Contractor <br /> 111 R1_T i} _Lp1L*Address License No. 3o a. Phone 5 d "»;• ti <br /> "' TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT L-3DESTRUCTION ❑ F <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SL-,'VER LINES DISPOSAL FLD. PROP. LINE �+ r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a • <br /> ❑ Industrial I O Open Bottom C1 Manteca Dia. of Well Excavation Dia.of Well Casing , p <br /> ❑ Gravel Pack ❑Tracy Type of Casing. Specifications <br /> ❑ Domestic/Private ' <br /> Tyre of Grout <br /> Public ❑ Other C] Delta Depth of Grout Seal <br /> ti oa <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair V.irk Done ❑ Type of Pump H.P. State Work Done <br /> "k k � <br /> Well Destruction G Well Diameter Sealing Material(top 501 ¢ ' <br /> x Depth_ Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TRUCTION ❑ (No septic system permitted if public sewer is e ; <br /> available within 200 feet.) 66`, Yh t <br /> a Irmtallation will serve: Residence ommercial_ ther <br /> `•j Number of living units:__L Number of edrooms <br /> ' Character of soil to a depth of 3 feet: [� Water table depth_ <br /> Capacity No. Compartments <br /> SEPTIC TANK hype/Mfg /� kk <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ � 1 'tip � <br /> Distance to nearest: Well 1�O Foundation_ S Property Line Y 'rR. <br /> y <br /> To�al length/size L' 4 <br /> LEACHING LINE & Length of lines 4- <br /> a ti <br /> FILTER BED ❑ Distance to nearest: Well� Foundatio,: — Property Line _KIE� <br /> SEEPAGE PITS �Spth Size_ �T -� Number <br /> SUMPS <br /> Distance to nearest: Well L Foundation!1— Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify thai I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,anc <br /> rules and reglJatiO�is of the San Joaquin Local Health District. <br /> Home owry,r or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I she not a ; <br /> employ any perso i in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature , <br /> Y`. r'. ,1 <br /> r pct to workman's corn nsa- <br /> certifies thglpll,wing:"I%rmfifryat in the performance of the work for whichthis permit is issuedI shall employ pe sons sub' Pe uire 'neper. ns. m drawing on r/e'vyerse side. <br /> Title: l Date: 6 t <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> Application Accepted by / Q ; ✓t <br /> Date Final Ir-pecoon by Dat " 1" <br /> Pit or Grout Inspection by <br /> Additional Comments: Tj <br /> El Stk 466-6781 F-, Lodi 369.36'11 ❑ Manteca 52.3.7104 i Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AW, P.O. Box 2009, Stk., CA 95201 i <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EH 13-24 iHEV. <br /> EH 14:6 <br />