Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> y (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 Ryles and Regulations of the San Joaquin <br /> Local Health District: <br /> Job Address f� r <br /> = City Lot Size PM <br /> Owner's.Name 9`� ddress Phone <br /> r '-- �G �L <br /> Con"tractor Address License No�3_T-3T 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> i <br /> + FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Ria. of Well Casing-i-- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin F ' <br /> - Yp g Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ° ' <br /> I i Type of Grout <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done � <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50') <br /> c -sr <br /> Depth � Filler <br /> Maa terialt .(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION) DESTRUCTION F] (No septic system permitted if public sewer is <br /> V <br /> e�i�.«-__ available within 200 feet.). <br /> Installation will serve: Residence �' Commercial Other r r <br /> Number of living units: -J— Number of bedr ours } 'r <br /> r <br /> Character of soil to a depth of 3 feet: Water table depth 10 _ <br /> SEPTIC TANK.' i ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT:❑ <br /> r•t. �' <br /> r' b °I Method of Disposal <br /> Distance to`nearest: Wel Foun` dation Fes° Property Line <br /> t <br /> LEACHING LINE Ni.o. & Length of lines^ �` r Total length/sizes— <br /> FILTER BED ❑ Distance to nearest: �V1lell; d �F.Qu4dation" ZO l� .Property Line ,�.. <br /> _ _ . # 5 <br /> SEEPAGE PITS ��^� Oepth -^`a ^Size; Number <br /> SUMPS I -�/"Qistance, o„n�aCesf:� I f ' @ <br /> $ xt --”:� WgII Foundation ',� <br /> . �.s4�t __� Property Line <br /> DISPOSAL PONDS ❑ + . L ' ;# <br /> I hereby certify that I have prepared this application and that'the work will be done in accordance with San Joaquin count' 'ordil es, state laws, and er <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 became subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies�fhe following: "I certify that in the performance�f the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law s`,of,California." ; <br /> The applicant mu all•for all required ' ctions. Complete drawing on raver side. <br /> Signed I -`. Title: Date: <br /> .' :r t ,� "' F.VP4U ONLY <br /> i Application Accepted by *- } '+:;^. Date L C <br /> r reaPit or Grout spection by _�` p t1al inspection by Date �r <br /> Additional Comments: __ Ay <br /> - <br /> ❑ Stk 466-6781 ❑pL•odi; 369-3621 0 Manteca 823-7104 El Tracy 835-6385 11, <br /> Applicant- Return all copies to: Environmental Health Pelrniit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE���INFO - AMOUNT DCK 4 <br /> UE AMOUNT REMETfED ASH -RECEIVED-.BY_—, DATE, ._ PERMIT`NO.: <br /> t , <br /> EH 114-224 8(REv.,i s s) k Lit <br /> _ _., <br />