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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address W 3,3 ` CityLot Size . L.0 14-- PM <br /> Owner's Name 10L44L Address S 67ns ' Phone <br /> � , p <br /> Contractor Address Iked d License No. U )-1 Pho a ca <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by is �y( <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 \ <br /> } Depth Filler Material (Below 50') <br /> TYRtOF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: -I-- Number o b drooms _. <br /> Character of soil to a depth of 3 feet: ' hh Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I a <br /> Distance to nearest: Property Line <br /> - 1 <br /> LEACHING LINE Lle-NO- & Length of lines 1 r Total length/size <br /> FILTER BED EDDistayto nearest: Well Fo dation , Property Line ZA0i r <br /> SEEPAGE PITS• I.f Depth -Size Number ,,� <br /> SUMPS Ll Distance to nFoundation <br /> earest: Well I Property.Line_L Z0.-.I.-._ <br /> t�s _ <br /> DISPOSAL•PON S. .,,, r, <br /> hereby`certify that Ichave prepar6d this application and that the work-will be done in accordance with Sah -Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joagiiin_LocgLI,Health'Di-strict. <br /> Home owner or licensed agent's signaturg"cett+fie-the f� ollowing:'I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to work an s co"nsation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the pert mance of the w6 k for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." '- - . <br /> ,t 1 <br /> The app)cant must call fot' •required inspections. Complete drawing on ev�rse side. q <br /> Signed X t ! Title: Date: "� r <br /> FOR DEPARTMENT USE ONLY <br /> p 1 <br /> Application Accepted by f + Date r��3 Area I <br /> /or Glut Inspection by Date 'tet' Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk !456.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E] Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201FEE <br /> INFO AMOUNT DUE AM�O{UNT,[REMITTED CK 0_ CASH i RECEIVED]BY DATE Qy7 PERMIT NO. <br /> +.EHt3-24iREV.ii>asl IV �C1V �`"' "' U f� s �aC/ ��!{J V • �j�V" <br /> EH 14-26 <br />