Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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. 1$62 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> 1-794(1 t�-6o b. ACS �. <br /> Job Address ��' �- `'� �{ City Lot Size PM <br /> Owner's Name__\ l L��� Address Y 1 ��� Phone + <br /> Contfactort-x''iV T CFL Address MIZ LAMME� 01Y License No�ZJ 'l�� ` Phoneb � lop <br /> TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT ❑ 1 t DESTRUCTION ❑ \ <br /> PUMP INSTALLATION El SYSTEM REPAIR 11ti 9'"4 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK6ft LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTEIVM34ZE TYPE OF W PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ OpeAttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private I Pack ❑ Tracy Type of Casing Specifications <br /> 16 Public ❑ Other~ pth ❑ Delta Depth of Grout Seal Type of Grout <br /> ElIrrigation JApprox. De _ urface Seal Installed by <br /> Repair rk Done 11 Type of Pump H.P. State Work Done <br /> _) l bestruction ❑ Well Diameter Sealing Material {top 50.1 <br /> Depth Filler Material Melow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> _ / available within 240 feet./ <br /> Installation will serve: Residence t Commercial Other <br /> Number of living units: 4 Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1CC Capaci No. Compartments <br /> PKG. TREATMENT PLT. ❑ .+ Method of Disposal <br /> Distance to nearest: Welltt TO Foundation Property Line Fgh-0 <br /> LEACHING LINE 3 No. & Length of lines 0 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation � �__..._. Property Line 40° 'Dip "F_6 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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. <br /> Home ner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies h following: 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 California ' <br /> The app t mu I fo all re uir d inspections. Complete drawing on reverse ssiidd-eye "Q <br /> Sig Title: Date: -{1 <br /> ,.�(� ItL <br /> R DEPARTMENT USE ONLY C� r <br /> Application Accepted by l:�][o�. ybA%ahAhm _ Date �k e�- T Area <br /> Pit or Grout Inspection by Date Final Inspection by VY-1 cwl Date,Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 8354i385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 Xvalefton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED / RECEIVED BY DATE PERMWNO. <br /> INFO <br /> + EEH H 1428(REV.t 57 � O, J � ^ _TLl <br /> � �Y / �4-10 " +p w <br />