Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781. <br /> ! F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> I <br /> i 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 Rules and Regulations of the San Joaquin <br /> y Local Health District.. ,�r' �Q <br /> Job Address 7k� CitY �/lr� �+f' Lot Size <br /> 1:6 PM <br /> Owner's Na&IF 1.f /z C (/S Address ��9 �/ Q a J, Phone(T! 7411-1 <br /> cuRPs_R a/Z14.LI^FC, P0. ram <br /> Contractor Co h21 t� Address,&—w A.2. !�:, U01ficense No.W30% Phonea3 <br /> TYPE OF WELL/PUMP: ,NEW WEL WELL REPLACEMENT DESTRUCTION ❑ <br /> I PUMP INSTALL�A-TIIO��� SYSTEM REPAIR'.[] OTBER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 57D SEWER LINES DISPOSAL FLD$�PROP. LINE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> I INTENDED USE TYPE OF.WELL ` ROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> ❑ Industrial CTOP- Bottom Vj7 Manteca } Dia. of Weil Excavation Dia. of Well Casing, <br /> I � Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />' ('1 Public ❑ Other _ ❑ Delta Depth of Grout Seal S®F Type of Grout <br /> I i Irrigation _-.Approx. D th l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 T r <br /> p Type of Pump ��'I H.P. State Work done <br /> Well Destruction CI Wel! Diameter Sealing Materia! It 50') <br /> Depth /L40" ISO, Filter Material (Below 50') f <br /> T PE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION l,I- DESTR CTION I 1 (No septic system permitted if public sewer is V� <br /> available within 200 feet.) <br /> "Installation wi Residence ; Commercial— Other <br /> Number of living units: ber of bedrooms t j <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 'T r � 0 <br /> - ype/Mfg Capacity �'" � No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ r ' <br /> v + Method of Disposal <br /> Distance to nearest: Well 'Foundatro Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length <br /> FILTER BED �`— <br /> ❑ Distance to nearest: Well ,..Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Numbei I <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <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. .», 4, <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 i6 such manner as to become subject to workman's compensation 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 permit is issued,I shall employ persons subject to workman's compensa- <br /> .tion laws of California." F <br /> The applicant must call for ail required inspections. Complete drawing on reverse side. <br /> u <br /> Signed _ - Title: -Date: 7 <br /> 4. FOR DEPARTMENT USE ONLY ., <br /> Application Accepted by `J -7` "Dated Area <br /> Pit or Grout Inspection by ate ;i a'f I spection by, ��� `Date <br /> Additional Comments. — <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 OkS. ❑ Tracy 835-63136- 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 RECEIVED BY <br /> INFO CASH DATE f' PERMIT'NO. <br /> + EH 13-34{AEV.F i x 51 J ATA1 -7 <br /> C� �f_ <br /> EH 14-28- .�7"- __ "".'�`►..JJ a���`/y Y/ ,- �. 7 <br />