Laserfiche WebLink
a <br /> { , APPLICATION FOR PERMIT <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209)466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> is' <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 - ,Firs.l� City G Lot Size PM <br /> Owner's Name .� Address RAti /r>✓E Phone <br /> f f <br /> I /a s /�?7 ������ Phone <br /> Contractor�'�[�,/,"-�/GL.rG—� Address License No <br /> `�� <br /> ' TYPE OF WELL/PUMP: F. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO !NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi <br /> ❑ Industrial ❑ Open;Bottom 1 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel,Pack L) Trky Type of Casing Specifications <br /> �. M Public F Othd 1 '❑ Delta A Depth of Grout Sea] Type of Grout <br /> r I i Irrigation _Approx. Depth I I Easter Surface Seal Installed by - <br /> Repair Work Done ❑ Type of:Pump 4 H.P. State Work Done <br /> Well Destruction ❑ Well Dtemeter Sealing Material (top 501 cti' <br /> Depth Y Filler Material (Below 501 nl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR)ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> I ''� i v available within 200 feet.) <br /> Installafion will serve: Residence Commercial-L—,,.Other ( 0 <br /> Number of living units: .Number of�bedroonis,�,J _"--� r <br /> :y <br /> Character of soil to a depth of 31feet: A DaBeg Water table depth <br /> f SEPTIC TANK ❑ Type/Mfg Q ui _ Capacity_/I-M,"LNo. Compartments <br /> PKG. TREATMENT PLT. © -�r Method of Disposal <br /> I Distance to nearest: Well t er Foundation-/aProperty Line <br /> 7 <br /> ,.., <br /> LEACHING LINE No & Length of lines = ''� [°1 Total length/size F7 <br /> FILTER BEDDrstaroce to Heart qtr -'Wellg?C�i# Foundatrdn , <br /> Property Line <br /> SEEPAGE PITS M'-,.Depth r`"'` S+iie Number <br /> SUMPS ❑ Distance to-neareat: 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 /> Homa.ownp?,!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 a4,`y arson in such manner as to become subject.to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies tj.o fbllowing:"I certify that in the performance o6he work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ftion laws ol.California." <br /> The applicant must call Ito It re red-inspections. Complete drawing on reverse side. �] <br /> Signed X, !1G e l �_ F Title: 0 Date: _3i f�!�Q <br /> t FORD ARTMENT USE ONLY <br /> Application Accepted by ' Date 7Area <br /> Pit or Grout inspection by Date 1 Final Inspection by Date3-/7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOtiNTDUE AMOUNt"REMITTEDx CK RECEIVED BY DATE PERMIT-NO" <br /> INFO Q� y. CA54 <br /> EH 14-26 <br /> EH 13-21(REV.I/N 51 <br />