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 to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This apocation 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 Disuiicct. <br /> Job Address l��S �.� � i2e/ nl City`63C,910A) Lot Sim PM <br /> Owner's Name _ �.�l PK Address —0Phone <br /> — - <br /> i <br /> Contractor ss1�7 �(� I License Noc360 252 Phone <br /> TYPE OF WELL/PUMP: NEIN WELL WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION � SYSTEM REPAIR u OTHER ❑ <br /> NOA <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES Z.Ing,1•6_ DISPOSAL FLDN�1�- PROP. LINE <br /> FOUNDATION 30 _ AGRICULTURE WELL A1-_At OTHER WELLALIA� PIT'S/SUMPS 4.'Q L)C <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ l <br /> E. Industrial . ❑ Open Bottom O Manteca Dia. of WeV Excavation Dia.of Well Casing `5 j <br /> 6-Domestic?Private ❑ Gravel Pack G Tracy Type of Casing�� Specifications <br /> ❑ Public ❑ Other E Delta Depth of Grout Seal Type of Grou,&XIM <br /> ❑ Irrigation _Approx. Depth �❑��,,.E, m- <br /> am Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> j <br /> Well Destru Kion O Well Diameter Sealing Material (top 50') "r <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C7 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) S <br /> Installatlon will serve: Residence_ Commercial_ Other K <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.❑ Method of Disposal ' ! <br /> Distance to nearest: Well` Foundation Property Line r <br /> tt <br /> LEACHING LINE G No. & Length of lines Total length/size { <br /> FILTER BED ❑ Distance to nearest: Well _. Foundation^ Property Line <br /> SEEPAGE PITS ❑ Depth Size Number` <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ -' } <br /> f <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 /> 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 shat 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 Ca(ifor <br /> The applicant Z- call l' —'��' �� d--•.; I <br /> for•all required inspe 9. Complete dV4ving on reverse side. <br /> Signed - Title:�L� � f ( � Date: <br /> F DEPARTi41ENT USE ONLY )r <br /> Application Accepted by Date Area 641i. <br /> PitGrout I dol (`.�1 Q <br /> pection by �:� 1 -tate_ :"� �� Final Inspection by CL Date <br /> Date <br /> Additional Comments: t <br /> ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836.6385 <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 AMOt1NT REMITTED RECEIVED BY DATE PERMlT"NO, <br /> INFO -CASH <br /> i EH 14.26(REV.x,991 �oS.C� Z,0,3o ND 11-I©- <br /> EH 1L28 — <br />