Laserfiche WebLink
s ro <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) 0_,qs-_ o'ev Q <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install 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. t2-ZSb ^/ . <br /> Job Address _ J_ �� 7" i4/R3 E-7 City Lot Size PM <br /> Owner's Name Address Phone <br /> �cDPiYYfSL:BL flCl�u�S SON .1V074;rC6f A 5V I G,*— <br /> Contractor.st -VI2License No. Phone b� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSz tf <br /> Y <br /> ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation� t�r 4 Dia. of Well Casing <br /> I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout —I I Irrigation _Approx, Depth 1 I Eastern Surface Seal Installed by 1 1" <br /> Repair Work Done ❑ Type of Pump r/ H.P, . State Work Done <br /> Well Destruction ❑ Well Diameters_ Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other p � Is 'a,1pjry <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. l❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: "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 /> The appli&anj must call for all required in ctions. Oomplate drawing on reverse side. <br /> Signe Title: C31C2..4-, u^!-� �c..laf�lg <br /> FOR DEPARTMENT USE ONLY �Q" <br /> Application Accepted by Date 2 s—Z� o 9' Area <br /> -132 <br /> Pit or Grout Inspection by r aZ I 4!IJf!!FQ"n D <br /> Additional Comments: D ne. SOD < <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK i1i DATE PERMIT-NO. <br /> ..EH 1 -241REV.t/K5Y <br /> EH 144-2e I G <br /> - j <br />