Laserfiche WebLink
APPLICATION FOR PERMIT T;A <br /> i L <br /> SAN JOAQUIN LOCAL HE kLTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4(6-6781 <br /> PERMIT EXPIRES I YEAR FRDM DATE ISSUED [:NVIROWIENTAL HEALTH <br /> (Complete in Tripicate) <br /> FER1,A1'[/SERV10ES <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> GtJfS 2 <br /> Job Address 4�� 50SOS :ity 5�e Lot Size 4ro;�, /,',, I <br /> PM c)9, <br /> Owner's Name <br /> 57 <br /> ContractorPhone <br /> Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL eg WELL REPLACE VIENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION Ll SYSTEM R:-:PAIR Ll OTHER 0 <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 /> El Industrial 0 Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing <br /> D Domestic/Private PCGravel Pack 29 Tracy Type of Casing PUC Specifications <br /> 0 Public 0 Other F1 Delta Depth of Gr ut Seal Type of Grout <br /> Depth El Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. — State Work Done <br /> Well Destruction C1 Well Diameter Sealing Material (top 501 <br /> Depth Fillet Material (Below!V) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I❑ REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: , ater table depth <br /> SEPTIC TANK El Type/Mfg Cap city No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Dista to nearest Well Fo ation Property Line <br /> LEACHING LINE No. & Length of lines Total length/s' <br /> FILTER BED 0 Distance to nearest: Foundation operty Line <br /> 7SEAS_G E PITS C] Depth Size Number <br /> UMP Dista <br /> c <br /> 'e to n., <br /> 'res, Property Line <br /> UMPS Well Foundation <br /> DISPOSAL PONDS D <br /> I hereby certify that I have prepared this application and that the work will be don p 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 compensatim 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 rmit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant nlyst call for ariinspections ompleta drawing on reverse ;ide. <br /> Signed X Title: kell-11 I u'/` Date: <br /> 1 A N NLY <br /> Application Accepted by Date 11? - Area <br /> Jr- <br /> Pit or Grout Inspac, on Date Fin il Inspection byDate <br /> AdditionalZ50- <br /> 0 Stk 466 MI 0 Lodi 369-3621 0 Manteca 823-7104 0 "'racy 8fi-63EIi5000r17 I . <br /> Applicant-Return all copW to. Environmental Health Permit/Services 1601 E. H;zetton Ave., P.O. Box 2009; Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO.' <br /> INFO <br /> + EH 13-24 IREV.It 6 5) <br /> EH <br /> 14-28 <br />