Laserfiche WebLink
t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE"TON.,AVE., STOCKTON, CA ' <br /> Ye-Wphor4e�{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, <br /> Job Address 3 a la City Lot Size PM { <br /> Owners Nale [�,(� Phone R 3 <br /> Contractor Address 11 Z7icense No. 4�67qfa; <br /> TYPE OF ELL/PUMP: NtW WELL / WELL REPLACEMENT DESTRUCTION Ii <br /> { PUMP INSTALLATION L' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLIMPS <br /> INTENDED 1JSE—^'"TYPE OF WELL""PROBLEM AREA- CONSTRUCTION SPECIFICATION _ �r <br /> ❑ In strial ❑❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin i <br /> 'Domestic/Private L+1'Gravel Pack " 'LlTracy type of Casingj_ �[' Specifications ad,d flat <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout`Seal Cry ]r Ty a cf Grout ' <br /> 0- 1 — -� <br /> ❑ Irrigation SAD.-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of.Pump H.P. - t�' j State Work Done P/ <br /> Well Destruction � Well Diameter Sealing?Material (top 50') <br /> Depth i ��'�iller Material {Below 51 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> s s`• _ i available within 200 feet.) r <br /> y Installation will serve: 'Residence_ Commercial Other �..' <br /> Number of living units: `+ Number-of bedroomsr— <br /> r- <br /> Character of soil to a depth of 3 feet~ �` - ',Wafer table-ilepth <br /> •SEPTIC TANK ❑ T e/Mf ' _ Ca ae r ' t w <br /> YP 9 _ p hY No. Compartments <br /> %" w, <br /> `PKG. TREATMENT PLT. ❑ R .J # Method of Disposal <br /> Distance to nearest: Well 4 �Fobndation Property Line 1 <br /> LEACHING LINE- El- No. & Length of limes 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 /> I hereby certify that I have prepared this application and that the.work will.b_e done�in-accordance with San Joaquin county ordinances, state laws, and a <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 h manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> v certifies th <br /> lowing:"I ertify that i 'for <br /> ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f Calif nia." <br /> The app cant m t for al q ons Co cawing on r e si <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �_� Date - Area <br /> Pit or Grout Inspection by Date 7-� � Fina In ection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 711 A ��to <br /> [f� plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 tk., CA 95201 <br /> { <br /> INEE <br /> FO AMOUNT DUE AMOUNT REMITTED CASH Ci RECEIVED BY DATE PERMIT NO,. <br /> + EH 13-24(REV,1/B <br /> EH 1126 <br /> 5F , -- •-» ;. - .._ b 7� „� �b��3 <br /> + ZO <br />