Laserfiche WebLink
E APPLICATION FOR PERMIT <br /> l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> �! Telephone (209) 466-6781 <br /> I° PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� (Complete in Triplicate) application is <br /> k made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app J <br /> r ion is hereby <br /> No.549 for sewage or No. <br /> made in compliance with San Joaquin County Ordinance 1862 for well!pump and the Rules and Regulations <br /> Application of the San Joaquin <br /> li 1 <br /> Local Health District. S T PM <br /> C II ^- City Lot Size <br /> Job Address `� <br /> hone 1 <br /> ' <br /> Address <br /> 'i� � <br /> Owner's Name <br /> C <br /> !� License No.1—Phone <br /> Address <br /> Contractor _—— WELL REPLACEMENT ❑ DESTRUCTION <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: ,ii SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP, LINE <br /> SEWER LINES —_--- <br /> _ ""P1TS'1SIMVlPS�"� <br /> DISTANCE TO NEAREST: SEPTIC TANK _� � N�_-, ". - OTHER-WELL <br /> r -- - FOUNDATION �� AGRICULTURE WELL <br /> I <br /> I INTENDED USE JITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Dia. of Well Excavation <br /> ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Industrial l` <br /> s ❑ Tracy Type of Casing <br /> D Domestic/Private ❑ Grave! Pack Type of Grout <br /> F1 Other Cl Delta Depth of Grout Seal <br /> [1 Public .II ., - Surface Seal Installed by <br /> I I Irrigation .Approx. Depth 4 I Eastern State Work Done <br /> +` <br /> H,P. <br /> -Repair Work Done 0- Type of Pump <br /> Sealing Material (top 501 <br /> Well Destruction ❑ Wel! Diameter Filler Material (Below 50'1 <br /> Depth ermitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 4 1 REPAIR/ADDITION L 1 DESTRUCTION arvailablelwithin e200 feet.) <br /> I� Other <br /> installation will serve: Residence Commercial <br /> Number of living units: �" Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— No. Compartments <br /> SEPTIC TANK Q Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. [O Foundation Property Line <br /> Distance to nearest: Well <br /> 1 <br /> Total iengthlsize <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation <br /> al <br /> l I Depth Size _ Number _ - <br /> SEEPAGE PITS - � �-"'^` ""'Property Line <br /> " �`Ll"Distance io nearest:` Well"� '— "Foundation <br /> '"^SUMPS <br /> k 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, an <br /> rules and regulations of the San Joaquin Local Health District.gwork tor <br /> Home owner or licensed agent's ne gas tore certifies tbecome subject t. <br /> he Ito wlorkman'srtcompensation!ify that in the la soof California.he Contractor which <br /> lhiringl orr permit <br /> ub-contracting signaturepenso- <br /> employ any person in such <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 compens <br /> tion laws of California."I <br /> I The applicant must cal r all req M ed inspections. Complete drawing on reverse side. > <br /> Date: <br /> ( Title: <br /> Signed <br /> Zfiw�DEPARTMENT USE ONLY ter/F rlyr 102 / <br /> Date rea <br /> Application Accapted b s� <br /> II / Date.�-- Final Inspection by i <br /> Date) <br /> Pit or Grout inspection by <br /> Additional Comments: <br /> Stk 466-6781 II❑ Lodi 369-3621 ❑ Manteca 623 7164 ❑ Tracy 835-6385 <br /> P.O.ElBax 2009, Stk., CA 85201 <br /> Applicant- Return all copies to: Environmental Health PermitlServicas 1601.E: Hazelton Ave., P. <br /> CK RECEIVED BY DATE PERMIYNO. <br /> F7 E �► AMOUNT DUE AMOUNT REMITTED CASH <br /> e INFO <br /> + + EK 13-24(REV,r/m 5) 1 <br /> EH 14.26 - <br /> u ^• <br />