Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p} > <br /> 1601 E. HAZELTON AVE., STOCKTON, CAl;: ; <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED DEC.. <br /> (Complete in Triplicate) �IVy1R0 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he s��Pi75 s 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 � a Joaquin <br /> Local Health District. 40 iW <br /> Job Address 1 p _" "_.— City W/�, Lot Size PM <br /> 41 <br /> ®i 1 G Address TtO r+�D � A- 44 *0) ?'�`yr Phonet!% <br /> Owner's Name , <br /> i en Wv 77 9Y.S38 _F <br /> Contractor �� Address —License No.��� Phoned / <br /> TYPE OF WELL/PUMP: 'NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I M a1 'jb�wi <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 'A <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 to eks{ Dia. of Well Casing I b <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing «�i.�1 V�_ Specifications" <br /> ('1 Public ❑ Other' fl Delta Depth of Grout Seal "L L `ype of Grouter _ <br /> IMI rri` ti' nl't�+� �_Approx. Depth I 1 Eastern Surface Seal installed by C / _ <br /> Repair Work [bene ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW I\Numbe <br /> ON l l REPAIR/ADDITION 13 DESTRUCTION I ) eptic system permitted if public sewer is <br /> available within 200.feet.) <br /> Installation will serve: Residencmercial_ Other ' <br /> Number of living units: edrooms <br /> Character of soil to a depth of 3 Water table depth <br /> SEPTIC TANK 171Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: I Foundation Property.Line <br /> LEACHING LINE ❑ No. & Len of lines Total length/size i <br /> FILTER BED ❑ Dista to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> i <br /> DISPOSAL POND ❑ I <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 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 in 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." <br /> The applicant must call f r all required inspections. Complete drawing on reverse side. , <br /> Signed X Ce L� • Title: �� Date: IA6 `�3 <br /> be-, -P 9T l<0t30o / 1V1R <br /> f, DEPARTMENT USE ONLY <br /> Application Accepted byDate ' Area <br /> � r <br /> Pit or Grout Inspection by �`" Date �— p" Final Inspection by Date <br /> Additional Comments: <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ 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 RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 1 -241REV.IJAS1 <br /> EH 144-29 <br /> I <br />