Laserfiche WebLink
- II <br /> APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT `� I <br /> - 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J 6 , ;r. {Complete in Triplicate) <br /> Application is hereby madelto 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 Regulati s e San Joaquin <br /> Local Health District..,.' t. ; V /cyq r <br /> uu Cityy i Lot Size PM <br /> Job Address I, <br /> 1 f Brow Address ��V — Phone [01� Ll 3 �. <br /> Owner's Name } <br /> CLQ r 1C I1GL! �/ 2 -� <br /> Contractor's Name nse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONLL SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK *5_0 SEWER LINES DISPOSAL FLD. POOP. LINE <br /> s' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC NS t 3 <br /> ❑ Industrial ❑ Ope ttom ❑ Manteca Dia, of Well Ex at' Dia. of Well Casing ` <br />' ❑ Domes' d Private ravel Pack ❑ Tr Type of Casing Specifications(,(, <br /> [] p c <br /> [1 Other Delta Depth of Grout Seal Type of Grout �Tvv <br /> I rrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by J I� <br /> r Repair Work Done ❑ Type of Pump H.P. State Work Done U it <br /> Well Destruction' ❑ Well Diameter ``' Sealing Material (top 50') I!' <br /> I Depth Filler Material (Below 501 ,r, _J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) : 1 <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I ' <br /> 1. <br /> I SEEPAGE.PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line 'I <br /> DISPOSAL PONDS ❑ !� <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 ag ature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not fff <br /> employ any person in such anner a to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"1 c tat i ormanc of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> r tion laws of-Cal' rni ' <br /> The applican a for I r red i o plate drawing on �e e sides <br /> Signed Title. jA/►►IJ G Date: I <br /> FOR DEPART NT USE ONLY .-� <br /> T i <br /> Application Accepted by Data Area <br /> r <� <br /> r Pit or Grout Inspection by Date Final Inspection by Date 11 <br /> Additional Comments:. �( <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•'NO. <br /> 14 <br /> INFO CASH <br /> +EH1 <br /> 3-241REV.10!631 1? <br /> Eli 1426 l <br />