Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ii (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. il y� <br /> I Joh Address �609� s°' �4/nme--'S Rd City Lot Size �0�✓J'� PM <br /> I <br /> Owner's Name ZQ14 Address s .7v° - Phone <br /> OF <br /> - _._.--Confractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ("1 Public 1-1 Other ❑ Delta.-•-----.D.epth.,of.-G&out.Sea4Type of Grout _ <br /> I 1 Irrigation --.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material (top 6011, <br /> Depth � Filler Material (Below 50'I — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIRIADDITION I i DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> { available within 200 feet-) OS' <br /> tt <br /> Installation will serve: Residence l Commercial L__ Other f <br /> Number of living units: Number-bf;bedrooms <br /> Character of soil to a depth of 3 feet: O M Water table depth �✓r <br /> I SEPTIC TANK 7 Type/Mfg rP G,�sT""""� Ca acity �o� 70f-"-'"- -Nd. Compartments <br /> I r <br /> PKG. TREATMENT PLT. ❑ A� -. 1 1 Method of Disposal <br /> Distance to nearest: Well Agr - Foundatibn /0 Property LinJW1 <br /> LEACHING LINE ,J7 No. & Length of lines 3" 9L7 s''`ue Totallength4size <br /> FILTER BED 11Distance to nearest: Well Foundation 00 � Pa3perky'Eirie, :: - <br /> SEEPAGE PITS 11 Depth Size Number <br /> 4 SUMPS 0 Distance to nearest: Well Foundation Property Line ! € <br /> DISPOSAL PONDS ❑ <br /> t f <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. I <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fof which this permit is issued, IohaA rr& <br /> employ any person in such manner as to become subject to workman's compensation laws of California-"Con to's <br /> hiring or.sub-contracting$signatA <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall em ploy persons subjept�to workman's compensa <br /> tion laws of California." I <br /> The applicant must all for all,required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> ! FOR,DEPARTMENT USE ONLY ; I <br /> i <br /> Application Accepted by Date G '� Area u <br /> Pit or Grout Inspection by Date Final Inspection by ate f'01 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'-835-6385 <br /> F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AN9s��a0. Si <br /> k., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO ASH RECEIVED(3Y pA�fE PERMIT'NO. <br /> ��qq y��l�j �y `t <br /> +-EH 13-24 Wv,t i H 5) /��_ ,.,-/, iY !D ,00 r .D• �'� 1} �Ile 9 A ! <br /> EH 14-Za i av 4 <br /> 7 ' <br />