Laserfiche WebLink
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) <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. >, 9)9:57- (0j= I►7E:A► v ©&M <br /> Job Address ' City � N Lot Size "� PM <br /> . � 1 I <br /> €+ Owner's Name Address _ ®� � ^ _ Phone��� <br /> k 4 a�l^sd� k��►��G biasa �a,c�,gs3ss' <br /> ` ,Cantr�ctor � Address License iVacp% ', Phone <br /> ?`TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ — SYSTEM REPAIR ❑ OTHER O" <br /> DISTANCE TO NEAREST: SEPTIC,TANK� -SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ~'AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial 4 ''T- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q <br /> f`} Public f t Cl Other r f� Delta y Depth of Grout Seal Type of Grout Q <br /> I 1 Irrigation, _..Approxi` Depth I I Eastern I W�Surlace•Seal Installed by <br /> Repair WorktDone C] Type of Pump H.P. State Work Done_ __10 <br /> Well Destruction ❑ Well Diameter: "" Sealing Material (top 501 ' <br /> k Depth? ' Filler Material (Below 501 <br /> K YPE OF SEPTIC WORK., NEW INSTALLATION.['I REPAIR/ADDITIONX DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> r r, available within 200 feet 1 <br /> Installation will serve: Residence_ Commercial_ Other s <br /> Number of living units: _j__ Number of bedrooms 3 <br /> Character"of soil to a.depth of 3 feet: SAA a i Water table depth <br /> SEPTIC TANK }. j Type/Mfg QIf^�.�' k Capacity____..."_ No. Compartments _ 1 <br /> PKG. TREATMENT PLT. ❑ r Method of D spo>al/.&md <br /> Distance to nearesti _ Well+�" ' Foundation Property.Line <br /> LEACHING LINE No. &,Length of lines f 6"0 ti' � otal length/size <br /> FILTER BED ❑ Distance to:ne res i ,Well Foundation tri Property Line <br /> SEEPAGE PITS ( I Depth; Size` Number 1 <br /> t � <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 6 �`" " ; <br /> I hereby certify-that I have prepared this applicatiori bnd 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 of 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 work man's compensation lam-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 emplo_y persons subject to workman's compensa- <br /> tion lawsWCalffornia." I ; { <br />€ The appliI for I quir inspecti ns. Cor9plete drawing on re se side. + i <br /> Signed X Title: +r1r.cJ t Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area Y f yy-All <br /> Pit or Grout Inspection by Date Final Inspection bv Date <br /> J .r <br /> Additional Comments: �, <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ©"Manteca 823-7104 'AE) Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave`, P.O. Bax 2009, Stk., CA 95201 <br /> ' <br />+ IFEE NFO AMOUNT DUE AMOUNT REMITTED - ^4 GASH RECEIVED BY DATE PERMIT1NO. <br />+ +.EH13-24(REV.i i n s1 2d � <br /> r0Ls 131 <br /> i EH 1426 <br />