Laserfiche WebLink
APPLICATION IrOR.P.ERMIT <br /> SAN JOAQUIN LOCAL HEALTH`DISTRICT , <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> uct <br /> all the work <br /> n described,This <br /> cation <br /> Application is hereis <br /> w th SanoJoaqu nnCounty O dinalnce Nto.Joaquin Locaealh549 for sewage or INo. 1862 for welkldpump atnd the Rules and'Regulations of the San'Joaquin <br /> 6 <br /> made in compliantcMe � ' <br /> Local Health District. 00, <br /> p O`J %C•'1Z.i G <br /> City < Lot size � PM <br /> Job Address 21 <br /> Phone I <br /> Owner's Name tit1�� De` Address f <br /> G� ©� �4/V 7t4_A License No. Phone ��� , <br /> ContractorAddress <br /> 20 A r Ne <br /> TYPE OF WELL/PUMP: NEW WELL L] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Q Industrial ❑ Open Bottom ❑ Manteca .Dia. of Welh:Excavation <br /> i "` "� " ;"' 'k Specifications <br /> ❑ Trac Type of,Casing <br /> ❑ Domestic/Private ❑ Gravel Pack y Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other 171 Delta <br /> El Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done 171 Type of Pump a= <br /> Sealing Material Itop 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 501 <br /> I' Depth <br /> } REPAlRIADDITION C1 DESTRUCTION © alvailabseptic <br /> isystem <br /> r1�OD e�tted`if public sew <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION er is <br /> Installation will serve:--Residence I <br /> _ �} i e .6 <br /> i Number of living units:w4 Number_of bedrooms— �• ,. w >, yyatr table depth <br /> Character of soil to a.depth of Meet: -..-- : 3� , <br /> f �pGapacity No. Compartmentis <br /> SEPTIC TANK g Type/Mfg _. .- - <br /> z Methoof Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well — Foundation Linen t , <br /> ti <br /> � ...' Total Iengthlsize <br /> LEACHING LINE i ❑ _ No. & Length of lines <br /> Pro arty Line <br /> FILTER BEDi " ❑` Distance to nearest: ; Well l Foundation P T f <br /> ` s Number ( <br /> SEEPAGE PITS �i Cie Depth Size Property Line ` <br /> SUMPS . ❑ ` <br /> Distance to nearest: j'. Well Foundation , <br /> DISPOSAL PONDS [3 <br /> hereby certify that I have prepared this�appiication and_that the work will be;one in accordance with San Joaquin county ordinances, state laws, and <br /> I <br /> rules and regulations of the San Joaquin Local Health District. ,; <br /> rformance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: 'I celtify that in the pe <br /> employ any person in such manner as to Become subject to workman s compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the personfollowiin u certify that in the performance of the workforwhich this permit is issued,!shall employ persons subject to workman's compensa- <br /> �' tion laws of California."` <br /> The applicant must-call.f€or al squire spections. Complete drawing <br /> reverse side. ®y <br /> r �c'1b / Date: li Title: _—� <br /> Signed <br /> k 1' <br /> FOR DEPARTMENT USE ONLY <br /> i k <br /> Date -Area <br /> ! Application Accepted by LOH <br /> s ' i Final Inspection by Date <br /> Pit or Grout Inspection by Date -- <br /> Additional Comments: ' Tracy 835-6385 <br /> ❑ Stk 466-6781 El Lodi .369-3621 ❑-Manteca 823 7104 ." Stk. CA 9WO-1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, azelt�on Ave -y: !..�v . <br /> t CK, FIECEIVED _PERMIT'NO_` �.�-.—�•- <br /> E IFEENFO` _-AMOUNT-DUE AMDUNT REMl7TED- CASH <br /> +EH 13.24(REV.t i H 5y _ <br /> EH 14-26 <br />