Laserfiche WebLink
00 <br /> APPLICATION FOR PERMIT <br /> •SAN JOAQUIN LOCAL HEALTH DIST <br /> 1601 E HAZELTON AVE , STOCKTON,. CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete'en Triplicate) <br /> Application is heiaby made to the San Joaquin Local Health District for b 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 Wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health.Di-an^c�t <br /> Jab Address 1 �tSO y,Tnl __�lt4., City S'Ms � Lot Size PM <br /> Pho <br /> Owni.r s Name� 1��_SLti t� Address {O'YX� Lf1 K+ Y ne <br /> I 41s' Gss c �3 <br /> Contractor ji _ 4—fL'�gl► ' .7e' 9s• i se No7� Phone <br /> TYPE OF WELL/PUMP NEW WELL E DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES _ DISPOSAL FLO 1, PROP LINE <br /> . <br /> FOUNDATION _jam_ AGRICULTURE WELL VA--OTHER WELL—.PITS/SUMPS <br /> INTENDED USE. TYPE OF WFLI PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ft r <br /> El industrial ❑ Open Bott im f:'i Ma.nleca Dia of Wall EXCdvatlon 10Dia of Well Casing \ <br /> Cl Domestic/Private 0 Gravel Pack 1)Tracy Type of Casing ~ OVq Specifications <br /> Public IIA Other i l Delta D(.pth of Grout Seal err C"Type of Grout—99"4111. <br /> Irriyi��a°a'KY 50 Approx Depth l I Edmofn Surface Sail Installed by (L,11„Fn G1E1�1 ^I <br /> Repan Work Done [_1 Type of Pump H P � _ State Work Done— J <br /> Well Destruction ❑ Well Diameter __ _ Spalmq Material itop 50I -- <br /> i Depth _ Filler Material (Below 501 — <br /> } TYPE OF SEPTIC WORK NEW INSTAILATION I I til PAIRIADDITION 11. DESTRUCTION I I Wa septic system permitted if public sewer is <br /> I! available within 200 feet) <br /> • Installation will serve Residence Commerc I Other. <br /> — <br /> Residence <br /> of Irving units Number of bedroom _ <br /> Character of sod to a depth of 3 feet _ — Water table depth <br /> SEPTIC TANK 'El Type/Mfg _ Capacity No Compartments <br /> PKG TREATMENT PLT i 1 Method o1 Disposal <br /> Distance to nearest W.11 Foundation Property Line <br /> u_ t\ <br /> LEACHING LINE El No & Length of lines Y Total length/size- <br /> FILTER BED CI Distance to nearest Well Foun tion Properly Line ` <br /> SEEPAGE PITS 14 Depth Si _ _ —_ ._ Number <br /> SUMPS I I Distance to nediest Well Foundation Property Line <br /> DISPOSAL PONDS ( 1 <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 iri the performance of the work for which this permit is issued I shall not <br /> employ any person in such manner as to become subpart to workman s compensation laws of California Contractors 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 Cabforrna <br /> The applicant s call for all r utred inspections Complete drawing on rave se side 5,r,;- /T� iJiel7+U 1� <br /> 5 �AaTti-T u T Data 7 <br /> Sig nae – vii ' 4 *"_ t 7 <br /> Q � FORD RTMENT S ONLY + <br /> Application Accepted by '— _ Date f Area <br /> j f 1 p y�'17 Final Inspacuan bpi Data <br /> Pit or Grout Inspection by L r,/ <br /> Additional Comments rL ` <br /> EI Stk 466 6781 ❑ Lodi 369 3621 E3 Manteca 8237104 ❑Tracy 835-6385 <br /> Applicant Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave P 0 Box 2009;Sik, CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED UY DATE PERMIT NO <br /> Y 4.7 "54 <br /> a EN 132iri7EV r�N% INFO - <br /> EH 14 26 <br />