Laserfiche WebLink
.0 <br /> y fi <br /> APPLICATION FOR PERMIT <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 /> I <br /> Application is hereby made to the SanCJoaquin rdinance No.549 for sewage or permit <br /> No. 1862 and/or install the work <br /> and the Rules and In de R Regula <br /> of Thisapplication <br /> San l Joaquin <br /> made in compliance with San Joaquin tY <br /> Local Health District. & qms� A <br /> i(p S- ,iCity Lot Size PM <br /> Job Address 1 1 1 1 139th S t. <br /> Phone <br /> Address San <br /> Owner's Name 1 401 Halyard, Ste. 140 <br /> ense No. Pho(t6� d <br /> Contractor <br /> WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ soil—gas Sury y <br /> TYPE OF PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER)P< 5 f t. <br /> 1 0 f t. <br /> SEWER LINES ��— DISPOSAL FLD•1 O PROP. LINE ft <br /> DISTANCE TO NEAREST: SEPTIC TANK 5`— . PITS/SUMPS, <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__7-.— <br /> ❑ industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> �l Delta Depth of Grout Seal Type of Grout <br /> M Public )CKOther - <br /> 1�.-Approx. Depth l I Eastern Surface Seal Installed by <br /> 11 Irrigation N.P. State Work Done <br /> Repair Work Done ❑ Type o1 Pump Sealing Material Itop 501 <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRlADDITION t I DESTRUCTION i I aNailablleseptic <br /> wthin 200m Pfeetit�ed if public sewer is <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms " <br /> Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg i b�h' 'd <br /> PKG. TREATMENT PLT. ❑ V� i c <br /> Distance to nearest: Well Foundation <br /> PZrty.Line <br /> Total length/size6°2_) <br /> LEACHING LINE ❑ No. & Length of lines Pro ert Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P1., Y,. _ i l <br /> 4� 1 <br /> SEEPAGE PITS 11 Depth <br /> Size Number <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 /> ify that in the performance Of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert ng <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contrac <br /> subject to workmantrscampeture <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of California." <br /> The applicant must call for all requited inspections. Complete drawing on reverse side. 8I2I89 <br /> Signed X <br /> sf,��.`�4�/ 1 Title- Geologist Date: <br /> FOR DEPARTMENT�USENLY <br /> Date Area <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: `f5 O <br /> ❑ Stk 466-6781 El Lodi 369-3621 El Manteca 823-7104 ❑ Tracy <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> ♦ EH 13-24(REV. <br /> EH 14-2a <br />